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1.  Lessons from the Deployment of the SPIRIT App to Support Collaborative Care for Rural Patients with Complex Psychiatric Conditions 
We report the design and deployment of a mobile health system for patients receiving primary care-based mental health services (Collaborative Care) for post-traumatic stress disorder and/or bipolar disorder in rural health centers. Here we describe the clinical model, our participatory approach to designing and deploying the mobile system, and describe the final system. We focus on the integration of the system into providers’ clinical workflow and patient registry system. We present lessons learned about the technical and training requirements for integration into practice that can inform future efforts to incorporate health technologies to improve care for patients with psychiatric conditions.
doi:10.1145/3123024.3125610
PMCID: PMC5654636
mHealth; mental health; Collaborative Care; primary care; remote symptom monitoring; post-traumatic stress disorder; bipolar disorder; depression; participatory design; CommCare; ACM Classification Keywords: J.3 [Life and Medical Sciences]: Health
2.  Proceedings of the 14th annual conference of INEBRIA 
Holloway, Aisha S. | Ferguson, Jennifer | Landale, Sarah | Cariola, Laura | Newbury-Birch, Dorothy | Flynn, Amy | Knight, John R. | Sherritt, Lon | Harris, Sion K. | O’Donnell, Amy J. | Kaner, Eileen | Hanratty, Barbara | Loree, Amy M. | Yonkers, Kimberly A. | Ondersma, Steven J. | Gilstead-Hayden, Kate | Martino, Steve | Adam, Angeline | Schwartz, Robert P. | Wu, Li-Tzy | Subramaniam, Geetha | Sharma, Gaurav | McNeely, Jennifer | Berman, Anne H. | Kolaas, Karoline | Petersén, Elisabeth | Bendtsen, Preben | Hedman, Erik | Linderoth, Catharina | Müssener, Ulrika | Sinadinovic, Kristina | Spak, Fredrik | Gremyr, Ida | Thurang, Anna | Mitchell, Ann M. | Finnell, Deborah | Savage, Christine L. | Mahmoud, Khadejah F. | Riordan, Benjamin C. | Conner, Tamlin S. | Flett, Jayde A. M. | Scarf, Damian | McRee, Bonnie | Vendetti, Janice | Gallucci, Karen Steinberg | Robaina, Kate | Clark, Brendan J. | Jones, Jacqueline | Reed, Kathryne D. | Hodapp, Rachel M. | Douglas, Ivor | Burnham, Ellen L. | Aagaard, Laura | Cook, Paul F. | Harris, Brett R. | Yu, Jiang | Wolff, Margaret | Rogers, Meighan | Barbosa, Carolina | Wedehase, Brendan J. | Dunlap, Laura J. | Mitchell, Shannon G. | Dusek, Kristi A. | Gryczynski, Jan | Kirk, Arethusa S. | Oros, Marla T. | Hosler, Colleen | O’Grady, Kevin E. | Brown, Barry S. | Angus, Colin | Sherborne, Sidney | Gillespie, Duncan | Meier, Petra | Brennan, Alan | de Vargas, Divane | Soares, Janaina | Castelblanco, Donna | Doran, Kelly M. | Wittman, Ian | Shelley, Donna | Rotrosen, John | Gelberg, Lillian | Edelman, E. Jennifer | Maisto, Stephen A. | Hansen, Nathan B. | Cutter, Christopher J. | Deng, Yanhong | Dziura, James | Fiellin, Lynn E. | O’Connor, Patrick G. | Bedimo, Roger | Gibert, Cynthia | Marconi, Vincent C. | Rimland, David | Rodriguez-Barradas, Maria C. | Simberkoff, Michael S. | Justice, Amy C. | Bryant, Kendall J. | Fiellin, David A. | Giles, Emma L. | Coulton, Simon | Deluca, Paolo | Drummond, Colin | Howel, Denise | McColl, Elaine | McGovern, Ruth | Scott, Stephanie | Stamp, Elaine | Sumnall, Harry | Vale, Luke | Alabani, Viviana | Atkinson, Amanda | Boniface, Sadie | Frankham, Jo | Gilvarry, Eilish | Hendrie, Nadine | Howe, Nicola | McGeechan, Grant J. | Ramsey, Amy | Stanley, Grant | Clephane, Justine | Gardiner, David | Holmes, John | Martin, Neil | Shevills, Colin | Soutar, Melanie | Chi, Felicia W. | Weisner, Constance | Ross, Thekla B. | Mertens, Jennifer | Sterling, Stacy A. | Shorter, Gillian W. | Heather, Nick | Bray, Jeremy | Cohen, Hildie A. | McPherson, Tracy L. | Adam, Cyrille | López-Pelayo, Hugo | Gual, Antoni | Segura-Garcia, Lidia | Colom, Joan | Ornelas, India J. | Doyle, Suzanne | Donovan, Dennis | Duran, Bonnie | Torres, Vanessa | Gaume, Jacques | Grazioli, Véronique | Fortini, Cristiana | Paroz, Sophie | Bertholet, Nicolas | Daeppen, Jean-Bernard | Satterfield, Jason M. | Gregorich, Steven | Alvarado, Nicholas J. | Muñoz, Ricardo | Kulieva, Gozel | Vijayaraghavan, Maya | Adam, Angéline | Cunningham, John A. | Díaz, Estela | Palacio-Vieira, Jorge | Godinho, Alexandra | Kushir, Vladyslav | O’Brien, Kimberly H. M. | Aguinaldo, Laika D. | Sellers, Christina M. | Spirito, Anthony | Chang, Grace | Blake-Lamb, Tiffany | LaFave, Lea R. Ayers | Thies, Kathleen M. | Pepin, Amy L. | Sprangers, Kara E. | Bradley, Martha | Jorgensen, Shasta | Catano, Nico A. | Murray, Adelaide R. | Schachter, Deborah | Andersen, Ronald M. | Rey, Guillermina Natera | Vahidi, Mani | Rico, Melvin W. | Baumeister, Sebastian E. | Johansson, Magnus | Sinadinovic, Christina | Hermansson, Ulric | Andreasson, Sven | O’Grady, Megan A. | Kapoor, Sandeep | Akkari, Cherine | Bernal, Camila | Pappacena, Kristen | Morley, Jeanne | Auerbach, Mark | Neighbors, Charles J. | Kwon, Nancy | Conigliaro, Joseph | Morgenstern, Jon | Magill, Molly | Apodaca, Timothy R. | Borsari, Brian | Hoadley, Ariel | Scott Tonigan, J. | Moyers, Theresa | Fitzgerald, Niamh M. | Schölin, Lisa | Barticevic, Nicolas | Zuzulich, Soledad | Poblete, Fernando | Norambuena, Pablo | Sacco, Paul | Ting, Laura | Beaulieu, Michele | Wallace, Paul George | Andrews, Matthew | Daley, Kate | Shenker, Don | Gallagher, Louise | Watson, Rod | Weaver, Tim | Bruguera, Pol | Oliveras, Clara | Gavotti, Carolina | Barrio, Pablo | Braddick, Fleur | Miquel, Laia | Suárez, Montse | Bruguera, Carla | Brown, Richard L. | Capell, Julie Whelan | Paul Moberg, D. | Maslowsky, Julie | Saunders, Laura A. | McCormack, Ryan P. | Scheidell, Joy | Gonzalez, Mirelis | Bauroth, Sabrina | Liu, Weiwei | Lindsay, Dawn L. | Lincoln, Piper | Hagle, Holly | Wallhed Finn, Sara | Hammarberg, Anders | Andréasson, Sven | King, Sarah E. | Vargo, Rachael | Kameg, Brayden N. | Acquavita, Shauna P. | Van Loon, Ruth Anne | Smith, Rachel | Brehm, Bonnie J. | Diers, Tiffiny | Kim, Karissa | Barker, Andrea | Jones, Ashley L. | Skinner, Asheley C. | Hinman, Agatha | Svikis, Dace S. | Thacker, Casey L. | Resnicow, Ken | Beatty, Jessica R. | Janisse, James | Puder, Karoline | Bakshi, Ann-Sofie | Milward, Joanna M. | Kimergard, Andreas | Garnett, Claire V. | Crane, David | Brown, Jamie | West, Robert | Michie, Susan | Rosendahl, Ingvar | Andersson, Claes | Gajecki, Mikael | Blankers, Matthijs | Donoghue, Kim | Lynch, Ellen | Maconochie, Ian | Phillips, Ceri | Pockett, Rhys | Phillips, Tom | Patton, R. | Russell, Ian | Strang, John | Stewart, Maureen T. | Quinn, Amity E. | Brolin, Mary | Evans, Brooke | Horgan, Constance M. | Liu, Junqing | McCree, Fern | Kanovsky, Doug | Oberlander, Tyler | Zhang, Huan | Hamlin, Ben | Saunders, Robert | Barton, Mary B. | Scholle, Sarah H. | Santora, Patricia | Bhatt, Chirag | Ahmed, Kazi | Hodgkin, Dominic | Gao, Wenwu | Merrick, Elizabeth L. | Drebing, Charles E. | Larson, Mary Jo | Sharma, Monica | Petry, Nancy M. | Saitz, Richard | Weisner, Constance M. | Young-Wolff, Kelly C. | Lu, Wendy Y. | Blosnich, John R. | Lehavot, Keren | Glass, Joseph E. | Williams, Emily C. | Bensley, Kara M. | Chan, Gary | Dombrowski, Julie | Fortney, John | Rubinsky, Anna D. | Lapham, Gwen T. | Forray, Ariadna | Olmstead, Todd A. | Gilstad-Hayden, Kathryn | Kershaw, Trace | Dillon, Pamela | Weaver, Michael F. | Grekin, Emily R. | Ellis, Jennifer D. | McGoron, Lucy | McGoron, Lucy
doi:10.1186/s13722-017-0087-8
PMCID: PMC5606215
3.  Pharmacoepidemiologic analyses of opioid use among OEF/OIF/OND veterans 
Pain  2017;158(6):1039-1045.
Pharmacoepidemiologic analysis found that OEF/OIF/OND veterans have high rates of opioid use, characterized by moderate dose intensity and long treatment duration.
Abstract
There is a great deal of concern about opioid use in veterans, particularly those who served in Afghanistan (OEF) and Iraq (OIF and OND). The current study provides a detailed pharmacoepidemiologic analysis of opioid use among OEF/OIF/OND veterans from FY09 to FY12. Data from 3 data repositories from the Veterans Health Administration (VHA) were used to describe demographic, clinical, and medication characteristics associated with opioid use among OEF/OIF/OND veterans and among those with TBI. Logistic regression models were used to identify risks associated with chronic opioid use in FY12. Approximately 23% of all OEF/OIF/OND veterans and 35% of those with TBI received any opioid medications. Most received moderate doses ranging from 26 to 30 mg morphine equivalent dose daily. Median days of opioid use for all OEF/OIF/OND veterans were 30 to 40 days. Factors associated with chronic use in both groups included young age, male sex, white race, being married, and living in rural areas. A diagnosis of PTSD (odds ratio [OR] = 1.22, P < 0.0001), major depressive disorder (OR = 1.14, P < 0.0001), and tobacco use disorder (OR = 1.18, P < 0.0001) were strongly associated with chronic opioid use. Back pain was also strongly associated with chronic use (OR = 2.50, P < 0.0001). As pain severity increased the odds of chronic opioid use also increased: mild pain (OR = 3.76, P < 0.0001), moderate pain (OR = 6.80, P < 0.0001), and severe pain (OR = 8.49, P < 0.0001). Opioid use among OEF/OIF/OND veterans is characterized by moderate doses that are used over relatively long periods of time by a minority of veterans.
doi:10.1097/j.pain.0000000000000874
PMCID: PMC5427984  PMID: 28195856
Opioid; Veteran; Pharmacoepidemiology; Drug utilization; OEF/OIF/OND
4.  Cost-effectiveness of Collaborative Care for Depression in Human Immunodeficiency Virus Clinics 
Objective
To examine the cost-effectiveness of the HITIDES intervention.
Design
Randomized controlled effectiveness and implementation trial comparing depression collaborative care with enhanced usual care.
Setting
Three Veterans Health Administration (VHA) HIV clinics in the Southern US.
Subjects
249 HIV-infected patients completed the baseline interview; 123 were randomized to the intervention and 126 to usual care.
Intervention
HITIDES consisted of an off-site HIV depression care team that delivered up to 12 months of collaborative care. The intervention used a stepped-care model for depression treatment and specific recommendations were based on the Texas Medication Algorithm Project and the VA/Department of Defense Depression Treatment Guidelines.
Main outcome measure(s)
Quality-adjusted life years (QALYs) were calculated using the 12-Item Short Form Health Survey, the Quality of Well Being Scale, and by converting depression-free days to QALYs. The base case analysis used outpatient, pharmacy, patient, and intervention costs. Cost-effectiveness was calculated using incremental cost effectiveness ratios (ICERs) and net health benefit (NHB). ICER distributions were generated using nonparametric bootstrap with replacement sampling.
Results
The HITIDES intervention was more effective and cost-saving compared to usual care in 78% of bootstrapped samples. The intervention NHB was positive and therefore deemed cost-effective using an ICER threshold of $50,000/QALY.
Conclusions
In HIV clinic settings this intervention was more effective and cost-saving compared to usual care. Implementation of off-site depression collaborative care programs in specialty care settings may be a strategy that not only improves outcomes for patients, but also maximizes the efficient use of limited healthcare resources.
doi:10.1097/QAI.0000000000000732
PMCID: PMC4626259  PMID: 26102447
5.  Outcomes of a Partnered Facilitation Strategy to Implement Primary Care–Mental Health 
Journal of General Internal Medicine  2014;29(Suppl 4):904-912.
ABSTRACT
BACKGROUND
Implementing new programs and practices is challenging, even when they are mandated. Implementation Facilitation (IF) strategies that focus on partnering with sites show promise for addressing these challenges.
OBJECTIVE
Our aim was to evaluate the effectiveness of an external/internal IF strategy within the context of a Department of Veterans Affairs (VA) mandate of Primary Care–Mental Health Integration (PC-MHI).
DESIGN
This was a quasi-experimental, Hybrid Type III study. Generalized estimating equations assessed differences across sites.
PARTICIPANTS
Patients and providers at seven VA primary care clinics receiving the IF intervention and national support and seven matched comparison clinics receiving national support only participated in the study.
INTERVENTION
We used a highly partnered IF strategy incorporating evidence-based implementation interventions.
MAIN MEASURES
We evaluated the IF strategy using VA administrative data and RE-AIM framework measures for two 6-month periods.
KEY RESULTS
Evaluation of RE-AIM measures from the first 6-month period indicated that PC patients at IF clinics had nine times the odds (OR=8.93, p<0.001) of also being seen in PC-MHI (Reach) compared to patients at non-IF clinics. PC providers at IF clinics had seven times the odds (OR=7.12, p=0.029) of referring patients to PC-MHI (Adoption) than providers at non-IF clinics, and a greater proportion of providers’ patients at IF clinics were referred to PC-MHI (Adoption) compared to non-IF clinics (β=0.027, p<0.001). Compared to PC patients at non-IF sites, patients at IF clinics did not have lower odds (OR=1.34, p=0.232) of being referred for first-time mental health specialty clinic visits (Effectiveness), or higher odds (OR=1.90, p=0.350) of receiving same-day access (Implementation). Assessment of program sustainability (Maintenance) was conducted by repeating this analysis for a second 6-month time period. Maintenance analyses results were similar to the earlier period.
CONCLUSION
The addition of a highly partnered IF strategy to national level support resulted in greater Reach and Adoption of the mandated PC-MHI initiative, thereby increasing patient access to VA mental health care.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-014-3027-2) contains supplementary material, which is available to authorized users.
doi:10.1007/s11606-014-3027-2
PMCID: PMC4239280  PMID: 25355087
implementation research; primary care; mental health; health policy
6.  National Study of Discontinuation of Long-Term Opioid Therapy among Veterans 
Pain  2014;155(12):2673-2679.
Introduction
Veterans have high rates of chronic pain and long-term opioid therapy (LTOT). Understanding predictors of discontinuation from LTOT will clarify the risks for prolonged opioid use and dependence among this population.
Methods
All veterans with at least 90 days of opioid use within a 180 day period were identified using national Veteran's Health Affairs (VHA) data between 2009 and 2011. Discontinuation was defined as 6 months with no opioid prescriptions. We utilized Cox proportional hazards analysis to determine clinical and demographic correlates for discontinuation.
Results
A total of 550,616 met criteria for LTOT. The sample was primarily male (93%), and white (74%), with a mean age of 57.8 years. The median daily morphine equivalent dose was 26 mg and 7% received high-dose (>100 mg MED) therapy. At one year after initiation, 7.5% (N=41,197) of the LTOT sample had discontinued opioids. Among those who discontinued (20%, N=108,601), the median time to discontinuation was 317 days. Factors significantly associated with discontinuation included both younger and older age, lower average dosage and receiving less than 90 days of opioids in the previous year. While tobacco use disorders decreased the likelihood of discontinuation, co-morbid mental illness and substance use disorders increased the likelihood of discontinuation.
Conclusions
LTOT is common in the VHA system and is marked by extended duration of use at relatively low daily doses with few discontinuation events. Opioid discontinuation is more likely in veterans with mental health and substance use disorders. Further research is needed to delineate causes and consequences of opioid discontinuation.
doi:10.1016/j.pain.2014.09.034
PMCID: PMC4250332  PMID: 25277462
7.  Population-Level Cost-Effectiveness of Implementing Evidence-Based Practices into Routine Care 
Health Services Research  2014;49(6):1832-1851.
Objective
The objective of this research was to apply a new methodology (population-level cost-effectiveness analysis) to determine the value of implementing an evidence-based practice in routine care.
Data Sources/Study Setting
Data are from sequentially conducted studies: a randomized controlled trial and an implementation trial of collaborative care for depression. Both trials were conducted in the same practice setting and population (primary care patients prescribed antidepressants).
Study Design
The study combined results from a randomized controlled trial and a pre-post-quasi-experimental implementation trial.
Data Collection/Extraction Methods
The randomized controlled trial collected quality-adjusted life years (QALYs) from survey and medication possession ratios (MPRs) from administrative data. The implementation trial collected MPRs and intervention costs from administrative data and implementation costs from survey.
Principal Findings
In the randomized controlled trial, MPRs were significantly correlated with QALYs (p = .03). In the implementation trial, patients at implementation sites had significantly higher MPRs (p = .01) than patients at control sites, and by extrapolation higher QALYs (0.00188). Total costs (implementation, intervention) were nonsignificantly higher ($63.76) at implementation sites. The incremental population-level cost-effectiveness ratio was $33,905.92/QALY (bootstrap interquartile range −$45,343.10/QALY to $99,260.90/QALY).
Conclusions
The methodology was feasible to operationalize and gave reasonable estimates of implementation value.
doi:10.1111/1475-6773.12247
PMCID: PMC4254127  PMID: 25328029
Cost-effectiveness; implementation; depression
8.  Patterns of Opioid Use for Chronic Non-Cancer Pain in the Veterans Health Administration from 2009 to 2011 
Pain  2014;155(11):2337-2343.
Although opioids are frequently prescribed for chronic non-cancer pain (CNCP) among Veterans Health Administration (VHA) patients, little has been reported on national opioid prescribing patterns in the VHA. Our objective was to better characterize the dosing and duration of opioid therapy for CNCP in the VHA. We analyzed national VHA administrative and pharmacy data for fiscal years 2009 to 2011. For individuals with CNCP diagnoses and any opioid use in the fiscal year, we calculated the distribution of individual mean daily opioid dose, individual total days covered with opioids in a year, and individual total opioid dose in a year. We also investigated the factors associated with being in the top 5% of individuals for total opioid dose in a year, which we term receipt of high volume opioids. About half of the patients with CNCP received opioids in a given fiscal year. The median daily dose was 21 milligrams morphine equivalents. Approximately 4.5% had a mean daily dose higher than 120 milligram morphine equivalents. The median days covered in a year was 115 to 120 days in these years for those receiving opioids. Fifty-seven percent had at least 90 days covered with opioids per year. Major depression and post-traumatic stress disorder were positively associated with receiving high volume opioids, but non-opioid substance use disorders were not. Among VHA patients with CNCP, chronic opioid therapy occurs frequently, but for the large majority of patients the average daily dose is modest. Doses and duration of therapy were unchanged 2009–2011.
doi:10.1016/j.pain.2014.08.033
PMCID: PMC4252255  PMID: 25180008
chronic noncancer pain; opioids; Veterans
11.  Reduction of Patient-Reported Antidepressant Side Effects in Collaborative Care 
OBJECTIVE
Antidepressants are effective for treating depression; collaborative care increases initiation of and adherence to antidepressants. Side effects of antidepressants are common and can adversely impact quality of life. Care managers address antidepressant side effects directly, but the impact of collaborative care on adverse effects is unknown. This secondary data analysis tested the hypothesis that patient-reported antidepressant side effects were lower in depressed patients receiving high-intensity, telemedicine-based collaborative care (TBCC) compared with those receiving low-intensity practice-based collaborative care (PBCC).
METHODS
This analysis used data from 190 patients enrolled in a pragmatic, multi-site, comparative-effectiveness trial from 2007–2009 and followed for 18 months. The majority of patients were female (83%) and Caucasian (75%). The mean age was 50±11.1. Patients randomized to PBCC received 12 months of evidence-based care from an on-site primary care provider and nurse care manager. TBCC patients received evidence-based care from an on-site primary care provider supported by an off-site telephone nurse care manager, tele-pharmacist, tele-psychologist and tele-psychiatrist. Telephone interviews completed at baseline, 6, 12 and 18 months included assessments of sociodemographics, beliefs about antidepressant treatment, depression severity, psychiatric comorbidity, medications, adherence, and side effects.
RESULTS
Controlling for baseline case-mix and time-variant medication characteristics (e.g., number, dose, or specific antidepressant), the TBCC group reported significantly fewer side effects at 6 and 12 months (p=.02 and .01, respectively). The number of antidepressants prescribed increased risk of side effects (p=.03).
CONCLUSIONS
Patients in the TBCC group reported fewer antidepressant-related side effects which may have contributed to improved quality of life.
doi:10.1176/appi.ps.201300570
PMCID: PMC4482336  PMID: 25727115
Depression; Adherence; Antidepressants; Telemedicine; Collaborative Care; Side Effects
12.  The Role of Gender in Moderating Treatment Outcome in Collaborative Care for Anxiety 
Objective
The aim of this study was to test whether gender moderates intervention effects in the Coordinated Anxiety Learning and Management (CALM) intervention, a 12-month, randomized controlled trial of a collaborative care (CC) intervention for anxiety disorders (panic disorder, generalized anxiety disorder, posttraumatic stress disorder, and social anxiety disorder) in 17 primary care clinics in California, Washington, and Arkansas.
Methods
Participants (n = 1004) completed measures of symptoms (Brief Symptom Inventory; BSI) and functioning (Mental and Physical Health Components of the Short Form-12; (MCS and PCS), and Healthy Days, Restricted Activity Days Scale) at baseline, 6, 12, and 18 months. Data on dose, engagement, and beliefs about psychotherapy were collected for patients in the CC group.
Results
Gender moderated the relationship between treatment and its outcome on the BSI, MCS and Healthy Days but not on the PCS. Women who received CC showed clinical improvements on the BSI, MHC, and Healthy Days that were significantly different from women in Usual Care. There were no differences for men in CC compared to Usual Care on any measures. In the intervention group, women attended more sessions of psychotherapy, completed more modules of therapy, expressed more commitment and viewed psychotherapy as more helpful than men.
Conclusions
These findings contribute to the broader literature on treatment heterogeneity, in particular the influence of gender, and may inform personalized care for persons seeking anxiety treatment in primary care settings.
doi:10.1176/appi.ps.201400049
PMCID: PMC4453769  PMID: 25727114
13.  Protocol: Adaptive Implementation of Effective Programs Trial (ADEPT): cluster randomized SMART trial comparing a standard versus enhanced implementation strategy to improve outcomes of a mood disorders program 
Background
Despite the availability of psychosocial evidence-based practices (EBPs), treatment and outcomes for persons with mental disorders remain suboptimal. Replicating Effective Programs (REP), an effective implementation strategy, still resulted in less than half of sites using an EBP. The primary aim of this cluster randomized trial is to determine, among sites not initially responding to REP, the effect of adaptive implementation strategies that begin with an External Facilitator (EF) or with an External Facilitator plus an Internal Facilitator (IF) on improved EBP use and patient outcomes in 12 months.
Methods/Design
This study employs a sequential multiple assignment randomized trial (SMART) design to build an adaptive implementation strategy. The EBP to be implemented is life goals (LG) for patients with mood disorders across 80 community-based outpatient clinics (N = 1,600 patients) from different U.S. regions. Sites not initially responding to REP (defined as <50% patients receiving ≥3 EBP sessions) will be randomized to receive additional support from an EF or both EF/IF. Additionally, sites randomized to EF and still not responsive will be randomized to continue with EF alone or to receive EF/IF. The EF provides technical expertise in adapting LG in routine practice, whereas the on-site IF has direct reporting relationships to site leadership to support LG use in routine practice. The primary outcome is mental health-related quality of life; secondary outcomes include receipt of LG sessions, mood symptoms, implementation costs, and organizational change.
Discussion
This study design will determine whether an off-site EF alone versus the addition of an on-site IF improves EBP uptake and patient outcomes among sites that do not respond initially to REP. It will also examine the value of delaying the provision of EF/IF for sites that continue to not respond despite EF.
Trial registration
ClinicalTrials.gov identifier: NCT02151331
doi:10.1186/s13012-014-0132-x
PMCID: PMC4189548  PMID: 25267385
Adaptive intervention; Depression; Health behavior change; Care management
14.  Individual and Contextual-Level Factors Associated with Continuity of Care for Adults with Schizophrenia 
This retrospective cohort study examined rates of conformance to continuity of care treatment guidelines and factors associated with conformance for persons with schizophrenia. Subjects were 8,621 adult Ohio Medicaid recipients, aged 18–64, treated for schizophrenia in 2004. Information on individual-level (demographic and clinical characteristics) and contextual-level variables (county socio-demographic, economic, and health care resources) were abstracted from Medicaid claim files and the Area Resource File. Outcome measures captured four dimensions of continuity of care: (1) regularity of care; (2) transitions; (3) care coordination, and (4) treatment engagement. Multilevel modeling was used to assess the association between individual and contextual-level variables and the four continuity of care measures. The results indicated that conformance rates for continuity of care for adults with schizophrenia are below recommended guidelines and that variations in continuity of care are associated with both individual and contextual-level factors. Efforts to improve continuity of care should target high risk patient groups (racial/ethnic minorities, the dually diagnosed, and younger adults with early onset psychosis), as well as community-level risk factors (provider supply and geographic barriers of rural counties) that impede access to care.
doi:10.1007/s10488-013-0500-x
PMCID: PMC3883973  PMID: 23689992
Continuity of care; Schizophrenia; Quality of care; Medicaid
15.  Patient Acceptance, Initiation, and Engagement in Tele-psychotherapy in Primary Care 
Objective
To examine factors associated with the utilization of psychotherapy offered in primary care over interactive video (tele-psychotherapy).
Methods
Primary care patients with depression (N=179) recruited from five Federally Qualified Health Centers were randomized to a telemedicine-based collaborative care intervention and offered free tele-psychotherapy in the primary care setting. Independent variables included measures of access and need for depression treatment. Logistic regression indentified variables associated with acceptability, initiation and engagement in tele-psychotherapy.
Results
76% of patients reported that psychotherapy was acceptable, 38% scheduled a tele-psychology session, 17% attended a session and 8% engaged in treatment (≥8 sessions). Because the intervention was designed to minimize treatment barriers, access was not a significant predictor of utilization. However, use of tele-psychotherapy was significantly associated with measures of perceived need.
Conclusions
Even when psychotherapy is delivered in the primary care setting over interactive video to minimize barriers, few patients initiate or engage in tele-psychotherapy.
doi:10.1176/appi.ps.201200198
PMCID: PMC4046886  PMID: 23370530
16.  Practice Based Versus Telemedicine Based Collaborative Care for Depression in Rural Federally Qualified Health Centers: A Pragmatic Randomized Comparative Effectiveness Trial 
The American journal of psychiatry  2013;170(4):10.1176/appi.ajp.2012.12050696.
Objective
Practice Based Collaborative Care is a complex evidence-based practice that is difficult to implement in smaller primary care practices lacking on-site mental health staff. Telemedicine Based Collaborative Care virtually co-locates and integrates mental health providers into primary care settings. The objective of this multi-site randomized pragmatic comparative effectiveness trial was to compare the outcomes of patients randomized to Practice Based versus Telemedicine Based Collaborative Care.
Method
From 2007–2009, patients at Federally Qualified Health Centers serving medically underserved populations were screened for depression, and 364 patients screening positive were enrolled and followed for 18 months. Those randomized to Practice Based Collaborative Care received evidence-based care from an on-site primary care provider and nurse care manager. Those randomized to Telemedicine Based Collaborative Care received evidence-based care from an on-site primary care provider and off-site telephone nurse care manager, telephone pharmacist, tele-psychologist and tele-psychiatrist. The primary clinical outcomes were treatment response, remission and changes in depression severity
Results
There were significant group main effects for both response (OR=7.74, CI95=3.94–15.20, p<0.0001) and remission (OR=12.69, CI95=4.81–33.46, p<0.0001) and a significant overall group by time interaction effect for Hopkins Symptom Checklist depression severity (χ23=40.51, p<0.0001) with greater reductions in depression severity observed over time for those randomized to Telemedicine Based Collaborative Care. Improvements in outcomes appeared to be attributable to higher fidelity to the collaborative care evidence-base in the Telemedicine Based group.
Conclusions
Contracting with an off-site Telemedicine Based Collaborative Care team yields better outcomes than implementing Practice Based Collaborative Care with locally available staff.
doi:10.1176/appi.ajp.2012.12050696
PMCID: PMC3816374  PMID: 23429924
17.  Geographical Access and the Substitution of Traditional Healing for Biomedical Services in Two American Indian Tribes 
Medical care  2012;50(10):877-884.
Objectives
American Indians who live in rural reservation communities face substantial geographic barriers to care that may limit their use of health services and contribute to their well-documented health disparities. The purpose of this study was to examine the impact of geographical factors in access to care on the use of services for physical and mental health problems and to explore American Indians’ use of traditional healing services in relation to use of biomedical services.
Methods
We analyzed survey data collected from two tribes (Southwest and Northern Plains). Geographical access to the closest biomedical service was measured using a Geographic Information System, including road travel distance, elevation gain and reservation boundary crossing.
Results
Use of biomedical services was unaffected by geographical access for Northern Plains tribal members with mental health problems and for Southwest tribal members with physical or mental health problems. For members of the Northern Plains tribe with physical health problems, travel distance (p=0.007) and elevation gain (p=0.029) significantly predicted a lower likelihood of service use. The use of traditional healing was unrelated to biomedical service use for members of the Northern Plains tribe with physical or mental health problems and for members of the Southwest tribe with physical health problems. For members of the Southwest tribe with mental health problems, the use of biomedical services increased the likelihood of using traditional healing services.
Conclusions
Findings suggest that biomedical services are geographically accessible to most tribal members and that tribal members are not substituting traditional healing for biomedical treatments because of poor geographical access.
doi:10.1097/MLR.0b013e318268ab99
PMCID: PMC3446690  PMID: 22982736
American Indians; geographical accessibility; traditional healing
18.  Partnership for Implementation of Evidence-Based Mental Health Practices in Rural Federally Qualified Health Centers: Theory and Methods 
Background
Mental health and substance abuse are among the most commonly reported reasons for visits to Federally Qualified Health Centers (CHCs), yet only 6.5% of encounters are with on-site behavioral health specialists. Rural CHCs are significantly less likely to have on-site behavioral specialists than urban CHCs. Due to this lack of mental health specialists in rural areas, the most promising approach to improving mental health outcomes is to help rural primary care providers deliver evidence based practices (EBPs). Despite the scope of these problems, no research has developed an effective implementation strategy for facilitating the adoption of mental health EBPs for rural CHCs.
Objectives
To describe the conceptual components of an Implementation Partnership that focuses on the adaption and adoption of mental health EBPs by rural CHCs in Arkansas.
Methods
We present a conceptual model that integrates seven separate frameworks: 1) Jones and Wells’ Evidence-Based Community Partnership Model, 2) Kitson’s Promoting Action on Research Implementation in Health Services (PARiHS) implementation framework, 3) Sackett’s definition of evidence-based medicine, 4) Glisson’s organizational social context model, 5) Rubenstein’s Evidence-Based Quality Improvement (EBQI) facilitation process, 6) Glasgow’s RE-AIM evaluation approach, and 7) Naylor’s concept of shared decision making.
Conclusions
By integrating these frameworks into a meaningful conceptual model, we hope to develop a successful Implementation Partnership between an academic health center and small rural CHCs to improve mental health outcomes. Findings from this Implementation Partnership should have relevance to hundreds of clinics and millions of patients, and could help promote the sustained adoption of EBPs across rural America.
doi:10.1353/cpr.2012.0039
PMCID: PMC3702033  PMID: 22982852
Implementation; CBPR; FQHCs; Rural; Quality improvement
19.  Improving Access to VA Care 
Journal of General Internal Medicine  2011;26(Suppl 2):621-622.
doi:10.1007/s11606-011-1850-2
PMCID: PMC3191216  PMID: 21989612
20.  Use of Outpatient Care in Veterans Health Administration and Medicare among Veterans Receiving Primary Care in Community-Based and Hospital Outpatient Clinics 
Health Services Research  2010;45(5 Pt 1):1268-1286.
Objective
To examine differences in use of Veterans Health Administration (VA) and Medicare outpatient services by VA primary care patients.
Data Sources/Study Setting
VA administrative and Medicare claims data from 2001 to 2004.
Study Design
Retrospective cohort study of outpatient service use by 8,964 community-based and 6,556 hospital-based VA primary care patients.
Principal Findings
A significant proportion of VA patients used Medicare-reimbursed primary care (>30 percent) and specialty care (>60 percent), but not mental health care (3–4 percent). Community-based patients had 17 percent fewer VA primary care visits (p<.001), 9 percent more Medicare-reimbursed visits (p<.001), and 6 percent fewer total visits (p<.05) than hospital-based patients. Community-based patients had 22 percent fewer VA specialty care visits (p<.0001) and 21 percent more Medicare-reimbursed specialty care visits (p<.0001) than hospital-based patients, but no difference in total visits (p=.80).
Conclusions
Medicare-eligible VA primary care patients followed over 4 consecutive years used significant primary care and specialty care outside of VA. Community-based patients offset decreased VA use with increased service use paid by Medicare, suggesting that increasing access to VA primary care via community clinics may fragment veteran care in unintended ways. Coordination of care between VA and non-VA providers and health care systems is essential to improve the quality and continuity of care.
doi:10.1111/j.1475-6773.2010.01123.x
PMCID: PMC2965504  PMID: 20831716
Access/demand/utilization of services; Medicare; VA health care system; cohort analysis
21.  A Web-Based Clinical Decision Support System for Depression Care Management 
Objective
To inform the design of future informatics systems that support the chronic care model.
Study Design
We describe the development and functionality of a decision support system for the chronic care model of depression treatment, known as collaborative care. Dissemination of evidence-based collaborative care models has been slow, and fidelity to the evidence base has been poor during implementation initiatives. Implementation could be facilitated by a decision support system for depression care managers, the cornerstone of the collaborative care model. The Net Decision Support System (https://www.netdss.net/) is a free Web-based system that was developed to support depression care manager activities and to facilitate the dissemination of collaborative care models that maintain high fidelity to the evidence base.
Methods
The NetDSS was based on intervention materials used for a randomized trial of depression care management that improved clinical outcomes compared with usual care. The NetDSS was developed jointly by a cross-functional design team of psychiatrists, depression care managers, information technology specialists, technical writers, and researchers.
Results
The NetDSS has the following functional capabilities: patient registry, patient encounter scheduler, trial management, clinical decision support, progress note generator, and workload and outcomes report generator. The NetDSS guides the care manager through a self-documenting patient encounter using evidence-based scripts and self-scoring instruments. The NetDSS has been used to provide evidence-based depression care management to more than 1700 primary care patients.
Conclusion
Intervention protocols can be successfully converted to Web-based decision support systems that facilitate the implementation of evidence-based chronic care models into routine care with high fidelity.
PMCID: PMC3329751  PMID: 21348556
22.  Implementation outcomes of evidence-based quality improvement for depression in VA community based outpatient clinics 
Background
Collaborative-care management is an evidence-based practice for improving depression outcomes in primary care. The Department of Veterans Affairs (VA) has mandated the implementation of collaborative-care management in its satellite clinics, known as Community Based Outpatient Clinics (CBOCs). However, the organizational characteristics of CBOCs present added challenges to implementation. The objective of this study was to evaluate the effectiveness of evidence-based quality improvement (EBQI) as a strategy to facilitate the adoption of collaborative-care management in CBOCs.
Methods
This nonrandomized, small-scale, multisite evaluation of EBQI was conducted at three VA Medical Centers and 11 of their affiliated CBOCs. The Plan phase of the EBQI process involved the localized tailoring of the collaborative-care management program to each CBOC. Researchers ensured that the adaptations were evidence based. Clinical and administrative staff were responsible for adapting the collaborative-care management program for local needs, priorities, preferences and resources. Plan-Do-Study-Act cycles were used to refine the program over time. The evaluation was based on the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) Framework and used data from multiple sources: administrative records, web-based decision-support systems, surveys, and key-informant interviews.
Results
Adoption: 69.0% (58/84) of primary care providers referred patients to the program. Reach: 9.0% (298/3,296) of primary care patients diagnosed with depression who were not already receiving specialty care were enrolled in the program. Fidelity: During baseline care manager encounters, education/activation was provided to 100% (298/298) of patients, barriers were assessed and addressed for 100% (298/298) of patients, and depression severity was monitored for 100% (298/298) of patients. Less than half (42.5%, 681/1603) of follow-up encounters during the acute stage were completed within the timeframe specified. During the acute phase of treatment for all trials, the Patient Health Questionnaire (PHQ9) symptom-monitoring tool was used at 100% (681/681) of completed follow-up encounters, and self-management goals were discussed during 15.3% (104/681) of completed follow-up encounters. During the acute phase of treatment for pharmacotherapy and combination trials, medication adherence was assessed at 99.1% (575/580) of completed follow-up encounters, and side effects were assessed at 92.4% (536/580) of completed follow-up encounters. During the acute phase of treatment for psychotherapy and combination trials, counseling session adherence was assessed at 83.3% (239/287) of completed follow-up encounters. Effectiveness: 18.8% (56/298) of enrolled patients remitted (symptom free) and another 22.1% (66/298) responded to treatment (50% reduction in symptom severity). Maintenance: 91.9% (10/11) of the CBOCs chose to sustain the program after research funds were withdrawn.
Conclusions
Provider adoption was good, although reach into the target population was relatively low. Fidelity and maintenance were excellent, and clinical outcomes were comparable to those in randomized controlled trials. Despite the organizational barriers, these findings suggest that EBQI is an effective facilitation strategy for CBOCs.
Trial registration
Clinical trial # NCT00317018.
doi:10.1186/1748-5908-7-30
PMCID: PMC3353178  PMID: 22494428
23.  A Re-conceptualization of Access for 21st Century Healthcare 
Journal of General Internal Medicine  2011;26(Suppl 2):639-647.
Many e-health technologies are available to promote virtual patient–provider communication outside the context of face-to-face clinical encounters. Current digital communication modalities include cell phones, smartphones, interactive voice response, text messages, e-mails, clinic-based interactive video, home-based web-cams, mobile smartphone two-way cameras, personal monitoring devices, kiosks, dashboards, personal health records, web-based portals, social networking sites, secure chat rooms, and on-line forums. Improvements in digital access could drastically diminish the geographical, temporal, and cultural access problems faced by many patients. Conversely, a growing digital divide could create greater access disparities for some populations. As the paradigm of healthcare delivery evolves towards greater reliance on non-encounter-based digital communications between patients and their care teams, it is critical that our theoretical conceptualization of access undergoes a concurrent paradigm shift to make it more relevant for the digital age. The traditional conceptualizations and indicators of access are not well adapted to measure access to health services that are delivered digitally outside the context of face-to-face encounters with providers. This paper provides an overview of digital “encounterless” utilization, discusses the weaknesses of traditional conceptual frameworks of access, presents a new access framework, provides recommendations for how to measure access in the new framework, and discusses future directions for research on access.
doi:10.1007/s11606-011-1806-6
PMCID: PMC3191218  PMID: 21989616
access; e-health; digital; connectivity; veterans
24.  How Bad Is Depression? Preference Score Estimates from Depressed Patients and the General Population 
Health Services Research  2009;44(4):1406-1423.
Objective
To compare depression health state preference scores across four groups: (1) general population, (2) previous history of depression but not currently depressed, (3) less severe current depression, and (4) more severe current depression.
Data Sources
Primary data were collected from 95 general population, 163 primary care, and 83 specialty mental health subjects.
Study Design
Stratified sampling frames were used to recruit general population and patient subjects. Subjects completed cross-sectional surveys. Key variables included rating scale and standard gamble scores assigned to depression health state descriptions developed from the Patient Health Questionnaire-9 (PHQ-9) and SF-12.
Data Collection/Extraction Methods
Each subject completed an in-person interview. Forty-nine subjects completed test/retest reliability interviews.
Principal Findings
Depressed patient preference scores for three of six SF-12 depression health states were significantly lower than the general population using the rating scale and two of six were significantly lower using standard gamble. Depressed patient scores for five of six PHQ-9 depression health states were significantly lower than the general population using the rating scale and two of six were significantly lower using standard gamble.
Conclusions
Depressed patients report lower preference scores for depression health states than the general population. In effect, they perceived depression to be worse than the general public perceived it to be. Additional research is needed to examine the implications for cost-effectiveness ratios using general population preference scores versus depressed patient preference scores.
doi:10.1111/j.1475-6773.2009.00974.x
PMCID: PMC2739035  PMID: 19453391
Depression; rating scale; standard gamble; cost–utility; health-related quality of life
25.  Salvage Resection for Isolated Local and/or Regional Failure of Head/Neck Cancer Following Definitive Concurrent Chemoradiotherapy Case Series and Review of the Literature. 
Background: Primary management of advanced head/neck cancers involves concurrent chemoradiotherapy . Subsequently, regional and local failures are managed with resection but there have been few reports that describe the morbidity and disease control outcomes of surgical salvage in this setting. Methods: Retrospective analysis describes complications, survival, and patterns of failure after salvage resection of isolated local and/or regional failures of head/neck cancer following definitive concurrent chemoradiotherapy. Results: Sixteen patients were identified for inclusion: laryngectomy in 11 patients, oral cavity/oropharynx resection in 2 patients, and neck dissection alone in 4 patients. Ten patients required graft tissue reconstruction (6 pedicle and 4 free flap). Median post-operative hospitalization was 7 days (range 3-19), and 4 patients required hospital re-admission. At a median survivor follow-up of 15.8 months (range 4.3-34.9), 10 patients were alive (6 without evidence of disease). Seven patients experienced disease recurrence at a median 6.7 months (range 0-12.6) following salvage resection (2 with isolated distant failures). Estimated 2-year local/regional control, freedom from failure, and overall survival were 58%, 39%, and 58%, respectively. Conclusions: Surgical salvage after primary definitive concurrent chemoradiotherapy is feasible with toxicity and outcomes similar to prior radiotherapy alone or sequential chemotherapy and radiation. Local andregional recurrence remains the predominant pattern of failure.
PMCID: PMC3277417  PMID: 22363192
Head and neck neoplasms; Combined modality therapy; Salvage therapy; Organ preservation therapy

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