Faculty Bibliography

BACKGROUND: Telephone smoking cessation counseling is effective in the general population, but it is not clear how feasible telephone cessation programs are for smokers with housing problems. We compared the feasibility and acceptability of telephone tobacco cessation treatment among non-homeless veterans, homeless veterans residing in long-term VA housing (HUD-VASH), and homeless veterans not residing in HUDVASH housing. METHODS: These data were collected as part of a six-site VA trial evaluating the implementation of a telephone care coordination program for smokers who use VA mental health services. Mental health providers referred patients to the program. We collected housing status on all referred patients via medical record review at the time of referral. We categorized referred patients as "non-homeless" if they did not have any medical record documentation of homelessness in the year prior to their referral. We categorized patients as "HUD-VASH" if there was documentation that they were enrolled in the VA's HUD-VASH housing program at the time of referral. We categorized patients as "homeless" if they had medical record documentation of homelessness in the year prior to their referral and they were not enrolled in the VA's HUD-VASH program at the time of referral. All referred patients were contacted by phone to offer enrollment in the treatment program. Participants who enrolled were offered self-help materials, smoking cessation medications, and proactive multi-call telephone counseling. We used chi-square analyses to examine the ability of the program to reach and engage non-homeless, HUD-VASH, and homeless patients into treatment. RESULTS: This report describes the first 1074 patients referred to the program. 912 patients were classified as non-homeless, 87 as HUDVASH, and 75 as homeless. Non-homeless patients and HUD-VASH patients were equally likely to be reached by phone to offer treatment (79% versus 74%; OR=1.32, CI=.80-2.18), but homeless patients were significantly less likel!

BACKGROUND Diabetes mellitus is common in the elderly, and therapy offers many benefits but also has many risks. Experts suggest a hbA1c of < 8% indicates better care for people > 80 years old, but evidence-based guidelines specific to the elderly are scarce. OBJECTIVES To correlate serious episodes of hypoglycemia (blood sugar < 65 with symptoms) with patient-specific factors and medication use. METHODS Prospectively designed retrospective explicit electronic chart review of 140 patients randomly selected out of a pool of 525 consecutive patients with diabetes that visited our clinic 8/1-10/30/2010. We excluded subjects as follows: age < 65 (n=3), mislabeled as diabetics (n=6), no follow up visit 4/1-10/30/2011 (n=6), or no follow up HbA1c after enrollment (n=8). Serious hypoglycemia was defined as blood sugar less than 65 with reported symptoms. Chi2 and logistic regression techniques were used to investigate the efficacy (levels of HbA1c, LDL) and safety (serious hypoglycemia) of chosen medication classes and achieved therapeutic goals. RESULTS The mean age was 78+/-8 years (range 65-100). Other baseline characteristics and univariate results are shown in table 1. 96% were on statins, yet only 32% had an LDL <100. Serious hypoglycemia was found in 23 patients (20%), and on multivariable analysis was associated with use of sulfonylurea and insulin but not with age, chronic kidney disease, cognitive impairment or HbA1c level. CONCLUSION Serious hypoglycemia in the elderly was associated with medication class but not co-morbidities or level of diabetes control. (Figure presented)

BACKGROUND: Most smokers do not receive comprehensive, evidence-based treatment for tobacco use that includes intensive behavioral counseling along with pharmacotherapy. Further, the use of proven, tobacco treatments is lower among minorities than among Whites. The primary objectives of this study are to: (1) Assess the effect of a proactive care intervention (PRO) on population-level smoking abstinence rates (i.e., abstinence among all smokers including those who use and do not utilize treatment) and on utilization of tobacco treatment compared to reactive/usual care (UC) among a diverse population of smokers, (2) Compare the effect of PRO on population-level smoking abstinence rates and utilization of tobacco treatments between African American and White smokers, and (3) Determine the cost-effectiveness of the proactive care intervention. METHODS/DESIGN: This prospective randomized controlled trial identifies a population-based sample of current smokers from the Department of Veterans Affairs (VA) electronic medical record health factor dataset. The proactive care intervention combines: (1) proactive outreach and (2) offer of choice of smoking cessation services (telephone or face-to-face). Proactive outreach includes mailed invitation materials followed by an outreach call that encourages smokers to seek treatment with choice of services. Proactive care participants who choose telephone care receive VA telephone counseling and access to pharmacotherapy. Proactive care participants who choose face-to-face care are referred to their VA facility's smoking cessation clinic. Usual care participants have access to standard smoking cessation services from their VA facility (e.g., pharmacotherapy, smoking cessation clinic) and from their state telephone quitline. Baseline data is collected from VA administrative databases and participant surveys. Outcomes from both groups are collected 12 months post-randomization from participant surveys and from VA administrative databases. The primary outcome is self-reported smoking abstinence, which is assessed at the population-level (i.e., among those who utilize and those who do not utilize tobacco treatment). Primary analyses will follow intention-to-treat methodology. DISCUSSION: This randomized trial is testing proactive outreach strategies offering choice of smoking cessation services, an innovation that if proven effective and cost-effective, will transform the way tobacco treatment is delivered. National dissemination of proactive treatment strategies could dramatically reduce tobacco-related morbidity, mortality, and health care costs. CLINICAL TRIALS REGISTRATION: ClinicalTrials.gov: NCT00608426.

Research-based queries about patients' experiences often uncover suicidal thoughts. Human subjects review requires suicide risk management (SRM) protocols to protect patients, yet minimal information exists to guide researchers' protocol development and implementation efforts. The purpose of this study was to examine the development and implementation of an SRM protocol employed during telephone-based screening and data collection interviews of depressed primary care patients. We describe an SRM protocol development process and employ qualitative analysis of de-identified documentation to characterize protocol-driven interactions between research clinicians and patients. Protocol development required advance planning, training, and team building. Three percent of screened patients evidenced suicidal ideation; 12% of these met protocol standards for study clinician assessment/intervention. Risk reduction activities required teamwork and extensive collaboration. Research-based SRM protocols can facilitate patient safety by (1) identifying and verifying local clinical site approaches and resources and (2) integrating these features into prevention protocols and training for research teams.

Introduction: State smoking-cessation telephone Quitlines have become an integral part of the United States' public health strategy for helping smokers quit. It is unclear whether these Quitlines meet the needs of smokers with a mental illness, who have unique challenges during the quitting process and may benefit from more intensive treatment. We conducted a needs assessment survey of U.S. state Quitlines (N= 51, including Washington, D.C.) to learn how they work with mentally ill callers. Methods: Quitline representatives were asked whether they have or perform six services chosen to represent basic elements of treatment access, process, and structure for mentally ill smokers. Results: We had a 96 percent response rate to our inquiries. All surveyed Quitlines accept calls from mentally ill smokers, and all either train their counselors in mental health or their counselors have past mental health training. In addition, all Quitlines encourage mentally ill callers to discuss quitting with their usual care provider for safety reasons. However, only eight sun'eyed Quitlines screen callers for mental illness, nine use specific counseling protocols for mentally ill callers, and only three have self-help materials tailored for the mentally ill. Discussion: Future studies are needed to identify the most effective approaches to providing telephone-based care for smokers with mental illness.

ABSTRACT: BACKGROUND: Physicians are encouraged to counsel obese patients to lose weight, but studies measuring the quality of physicians' counseling are rare. We sought to describe the quality of physicians' obesity counseling and to determine associations between the quality of counseling and obese patients' motivation and intentions to lose weight, key predictors of behavior change. METHODS: We conducted post-visit surveys with obese patients to assess physician's use of 5As counseling techniques and the overall patient-centeredness of the physician.. Patients also reported on their motivation to lose weight and their intentions to eat healthier and exercise. One-way ANOVAs were used to describe mean differences in number of counseling practices across levels of self-rated intention and motivation. Logistic regression analyses were conducted to assess associations between number of 5As counseling practices used and patient intention and motivation. RESULTS: 137 patients of 23 physicians were included in the analysis. While 85% of the patients were counseled about obesity, physicians used only a mean of 5.3 (SD = 4.6) of 18 possible 5As counseling practices. Patients with higher levels of motivation and intentions reported receiving more 5As counseling techniques than those with lower levels. Each additional counseling practice was associated with higher odds of being motivated to lose weight (OR 1.31, CI 1.11-1.55), intending to eat better (OR 1.23, CI 1.06-1.44), and intending to exercise regularly (OR 1.14, CI 1.00-1.31). Patient centeredness of the physician was also positively associated with intentions to eat better (OR 2.96, CI 1.03-8.47) and exercise (OR 26.07, CI 3.70-83.93). CONCLUSIONS: Quality of physician counseling (as measured using the 5As counseling framework and patient-centeredness scales) was associated with motivation to lose weight and intentions to change behavior. Future studies should determine whether higher quality obesity counseling leads to improved behavioral and weight outcomes