Faculty Bibliography

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)

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.

OBJECTIVE: Translating Initiatives in Depression into Effective Solution (TIDES) aimed to translate research-based collaborative care for depression into an approach for the Veterans Health Administration (VA). SITES: Three multistate administrative regions and seven of their medium-sized primary care practices. INTERVENTION: Researchers assisted regional leaders in adapting research-based depression care models using evidence-based quality improvement (EBQI) methods. EVALUATION: We evaluated model fidelity and impacts on patients. Trained nurse depression care managers collected data on patient adherence and outcomes. RESULTS: Among 72% (128) of the 178 patients followed in primary care with depression care manager assistance during the 3-year study period, mean PHQ-9 scores dropped from 15.1 to 4.7 (p < .001). A total of 87% of patients achieved a PHQ-9 score lower than 10 (no major depression). 62% achieved a score lower than six (symptom resolution). Care managers referred 28% (50) TIDES patients to mental health specialty (MHS). In the MHS-referred group, mean PHQ-9 scores dropped from 16.4 to 9.0 (p < .001). A total of 58% of MHS-referred patients achieved a PHQ-9 score lower than 10, and 40%, a score less than 6. Over the 2 years following the initial development phase reported here, national policymakers endorsed TIDES through national directives and financial support. CONCLUSIONS: TIDES developed an evidence-based depression collaborative care prototype for a large health care organization (VA) using EBQI methods. As expected, care managers referred sicker patients to mental health specialists; these patients also improved. Overall, TIDES achieved excellent overall patient outcomes, and the program is undergoing national spread.

Objective: State smoking cessation telephone quitlines have become an integral part of the U.S. 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 compared to smokers without mental illness. We conducted a needs assessment survey of U.S. state quitlines (N=51 including Washington DC) 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. Findings: We had a 96% response rate to our survey. All surveyed quitlines accept calls from mentally ill smokers, and all either train their counsellors in mental health or their counsellors have past mental health training. In addition, all quitlines encourage mentally ill callers to discuss quitting with their regular healthcare providers for safety reasons. However, only eight surveyed quitlines (16%) screen callers for mental illness, few (18%) use specific counselling protocols for mentally ill callers, and even fewer (6%) have self-help materials tailored for the mentally ill. Conclusions: Future studies are needed to analyse these variations in state quitline operations to identify the most effective approaches to providing telephone-based treatment for smokers with mental illness.