Faculty Bibliography

BACKGROUND:Insulin titration is typically done face-to-face with a clinician; however, this can be a burden for patients due to logistical issues associated with in-person clinical care. The Mobile Insulin Titration Intervention (MITI) used basic cell phone technology including text messages and phone calls to help patients with diabetes find their optimal basal insulin dose (OID). OBJECTIVE:To evaluate sociodemographic and clinical correlates of reaching OID, text message response rate, and days needed to reach OID. METHODS:Primary care providers referred patients to MITI and nurses delivered the program. Three multivariable regression models quantified relationships between various correlates and primary outcomes. RESULTS:The sample included 113 patients from 2 ambulatory clinics, with a mean age of 50 years (SD = 10), 45% female, 79% Hispanic, 43% unemployed, and 46% uninsured. In regression models, baseline fasting blood glucose (FBG) was negatively associated with odds of reaching OID and 100% text responses, and positively associated with days to reach OID, p < .05). CONCLUSIONS:Patients with higher baseline FBG levels were less successful across outcomes and may need additional supports in future mHealth diabetes programs. PRACTICAL IMPLICATIONS/CONCLUSIONS:Basic cell phone technology can be used to adjust patients' insulin remotely, thereby reducing logistical barriers to care.

Background: Veterans with a mental health diagnosis have high rates of tobacco use, but encounter low rates of treatment and referrals from providers and limited treatment approaches addressing their unique barriers to cessation. This study aimed to determine whether an intensive proactive tobacco treatment approach increases treatment engagement and long-term abstinence rates in Department of Veterans Affairs (VA) mental health patients compared to visit-based usual tobacco care. Methods: The study used a randomized controlled trial design. Investigators used the electronic medical record at four VA facilities to identify patients documented as current smokers and who had a mental health clinic visit in the past 12 months. Patients were sent an introductory letter and baseline survey. Survey respondents were randomized to intervention (n=969) or control (n=969). Control participants received a list of usual VA smoking services. Intervention participants received a motivational outreach call, multi-session telephone counseling, and assistance with obtaining nicotine replacement therapy (NRT). Participants completed telephone surveys at 6 and 12 months to assess use of treatment, 7-day abstinence and prolonged 6-month abstinence. The primary outcome was self-reported 7-day abstinence from smoking at 12-month follow-up. Secondary outcomes included use of cessation treatment, self-reported 7-day abstinence at 6-month follow-up, and 6-month prolonged abstinence at 12-month follow-up. Mailed saliva samples were collected to verify self-reported 7-day abstinence at 12 months. Results: At 12 months, Intervention participants were more likely to report using telephone counseling (19% vs 3%, OR=7.34, 95%CI=4.59-11.74), NRT (47% vs 35%, OR=1.63, 95%CI=1.31-2.03) or both counseling and NRT (16% vs 2%, OR=11.93, 95%CI=6.34-22.47) compared to Control patients with access to usual care. Intervention participants were more likelyto report 7-day abstinence (19% vs. 14%, OR=1.50, 95%CI=1.12-2.01) and prolonged 6-month abstinence (16% vs 9%, OR=1.87, 95%CI=1.34-2.61). After adjusting for non-ignorable missingness at follow-up, the intervention effects on 7-day and prolonged abstinence remained significant (p<.05). Conclusions: Proactive tobacco treatment was more effective than usual VA care at increasing treatment engagement and long-term abstinence in mental health patients

PURPOSE/OBJECTIVE:We wanted to describe small, independent primary care practices' performance in meeting the Million Hearts ABCSs (aspirin use, blood pressure control, cholesterol management, and smoking screening and counseling), as well as on a composite measure that captured the extent to which multiple clinical targets are achieved for patients with a history of arteriosclerotic cardiovascular disease (ASCVD). We also explored relationships between practice characteristics and ABCS measures. METHODS:We conducted a cross-sectional, bivariate analysis using baseline data from 134 practices in New York City. ABCS data were extracted from practices' electronic health records and aggregated to the site level. Practice characteristics were obtained from surveys of clinicians and staff at each practice. RESULTS:= .011) than practices with multiple clinicians. CONCLUSION/CONCLUSIONS:Achieving targets for ABCS measures varied considerably across practices; however, small practices were meeting or exceeding Million Hearts goals (ie, 70% or greater). Practices were less likely to meet consistently clinical targets that apply to patients with a history of ASCVD risk factors. Greater emphasis is needed on providing support for small practices to address the complexity of managing patients with multiple risk factors for primary and secondary ASCVD.

INTRODUCTION/BACKGROUND:Veterans with a mental health diagnosis have high rates of tobacco use but encounter low rates of treatment from providers. This study tested whether a proactive tobacco treatment approach increases treatment engagement and abstinence rates in Department of Veterans Affairs mental health patients. STUDY DESIGN/METHODS:RCT. SETTING/PARTICIPANTS/METHODS:The study was performed from 2013 to 2017 and analyses were conducted in 2017. Investigators used the electronic medical record at four Veterans Administration facilities to identify patients documented as current smokers and who had a mental health clinic visit in the past 12 months. INTERVENTION/METHODS:Patients were mailed an introductory letter and baseline survey. Survey respondents were enrolled and randomized to intervention (n=969) or control (n=969). Control participants received a list of usual Veterans Administration smoking services. Intervention participants received a motivational outreach call, multisession telephone counseling, and assistance with obtaining nicotine replacement therapy. MAIN OUTCOME MEASURES/METHODS:Participants completed surveys at baseline, 6 months, and 12 months after randomization. The primary outcome was self-reported 7-day abstinence from cigarettes at 12-month follow-up. Secondary outcomes included use of cessation treatment, self-reported 7-day abstinence at 6-month follow-up, and 6-month prolonged abstinence at 12-month follow-up. RESULTS:At 12 months, intervention participants were more likely to report using telephone counseling (19% vs 3%, OR=7.34, 95% CI=4.59, 11.74), nicotine replacement therapy (47% vs 35%, OR=1.63, 95% CI=1.31, 2.03), or both counseling and nicotine replacement therapy (16% vs 2%, OR=11.93, 95% CI=6.34, 22.47). Intervention participants were more likely to report 7-day abstinence (19% vs 14%, OR=1.50, 95% CI=1.12, 2.01) and prolonged 6-month abstinence (16% vs 9%, OR=1.87, 95% CI=1.34, 2.61). After adjusting for non-ignorable missingness at follow-up, the intervention effects on 7-day and prolonged abstinence remained significant (p<0.05). CONCLUSIONS:Proactive outreach was more effective than usual Veterans Administration care at increasing treatment engagement and long-term abstinence in mental health patients. TRIAL REGISTRATION/BACKGROUND:This study is registered at www.clinicaltrials.gov NCT01737281.

BACKGROUND:The Mobile Insulin Titration Intervention (MITI) program helps patients with type 2 diabetes find their correct basal insulin dose without in-person care. Requiring only basic cell phone technology (text messages and phone calls), MITI is highly accessible to patients receiving care in safety-net settings. MITI was shown in a randomized controlled trial (RCT) to be efficacious at a New York City (NYC) safety-net clinic where patients often have challenges coming for in-person care. In 2016, MITI was implemented as usual care at Bellevue Hospital (the site of the original RCT) and at Gouverneur Health (a second NYC safety-net clinic) under 2 different staffing models. OBJECTIVE:This implementation study examined MITI's transition into real-world settings. To understand MITI's flexibility, generalizability, and acceptability among patients and providers, we evaluated whether MITI continued to produce positive outcomes in expanded underserved populations, outside of an RCT setting. METHODS:Patients enrolled in MITI received weekday text messages asking for their fasting blood glucose (FBG) values and a weekly titration call. The goal was for patients to reach their optimal insulin dose (OID), defined either as the dose of once-daily basal insulin required to achieve either an FBG of 80-130 mg/dL (4.4-7.2 mmol/L) or as the reaching of the maximum dose of 50 units. After 12 weeks, if OID was not reached, the patients were asked to return to the clinic for in-person care and titration. MITI program outcomes, clinical outcomes, process outcomes, and patient satisfaction were assessed. RESULTS:levels fell from 11.4% (101 mmol/mol) to 10.0% (86 mmol/mol), P<.001. Process outcomes show that 90.1% of MITI's text message prompts received a response, nurses connected with patients 81.9% of weeks to provide titration instructions, and 85% of attending physicians made at least one referral to the MITI program. Satisfaction surveys showed that most patients felt comfortable sharing information over text and felt the texts reminded them to take their insulin, check their sugar, and make healthy food choices. CONCLUSIONS:This implementation study showed MITI to have continued success after transitioning from an RCT program into real-world settings. MITI showed itself to be flexible and generalizable as it easily fits into a second site staffed by general medical clinic-registered nurses and remained acceptable to patients and staff who had high levels of engagement with the program.

OBJECTIVE:There is limited research on metabolic abnormalities in psychotropic-naïve patients with serious mental illness (SMI). Our study examined metabolic conditions in a large, ethnically diverse sample of psychotropic-naïve and non-naïve adults with SMI at an urban public hospital. METHODS:In this cross-sectional study of 923 subjects, the prevalences of hyperglycemia meeting criteria for type 2 diabetes mellitus (T2DM) based on fasting plasma glucose and obesity defined by BMI and abdominal girth were compared across duration of psychotropic medication exposure. Multiple logistic regression models used hyperglycemia and obesity as dependent variables and age, sex, race/ethnicity, and years on psychotropics as independent variables. RESULTS:Psychotropic-naïve patients, including both schizophrenia and non-psychotic subgroups, showed an elevated prevalence of hyperglycemia meeting criteria for T2DM and a decreased prevalence of obesity compared to the general population. Obesity rates significantly increased for those on psychotropic medications more than 5 years, particularly for patients without psychosis (BMI: aOR = 5.23 CI = 1.44-19.07; abdominal girth: aOR = 6.40 CI = 1.98-20.69). Women had a significantly higher obesity rate than men (BMI: aOR = 1.63 CI = 1.17-2.28; abdominal girth: aOR = 3.86 CI = 2.75-5.44). Asians had twice the prevalence of hyperglycemia as whites (aOR = 2.29 CI = 1.43-3.67), despite having significantly less obesity (BMI: aOR = .39 CI = .20-.76; abdominal girth: aOR = .34 CI = .20-.60). Hispanics had a higher rate of obesity by BMI than whites (aOR = 1.91 CI = 1.22-2.99). CONCLUSIONS:This study showed disparities between obesity and T2DM in psychotropic-naïve patients with SMI, suggesting separate risk pathways for these two metabolic conditions.

Introduction: Veterans with mental health disorders smoke at high rates, but encounter low rates of tobacco treatment. We sought to understand barriers and facilitators to treating tobacco use in VA mental health clinics. Methods: This qualitative study was part of a trial evaluating a telephone care coordination program for smokers using mental health services at 6 VA facilities. We conducted semi-structured interviews with 14 staff: 12 mental health clinic staff working at the parent study's intervention sites (n=6 psychiatrists, 3 psychologists, 2 social workers, 1 NP), as well as one psychiatrist and one psychologist on the VA's national tobacco advisory committee. Interviews were transcribed and inductively coded to identify themes. Results: Five "barriers" themes emerged: 1) competing priorities, 2) patient challenges/resistance, 3) complex staffing/challenging cross-discipline coordination, 4) mixed perceptions about whether tobacco is a mental health care responsibility, and 5) limited staff training/comfort in treating tobacco. Five "facilitators" themes emerged: 1) reminding mental health staff about tobacco, 2) staff belief in the importance of addressing tobacco, 3) designating a cessation medication prescriber, 4) linking tobacco to mental health outcomes and norms, and 5) limiting mental health staff burden. Conclusions: VA mental health staff struggle with knowing that tobacco use is important, but they face competing priorities, encounter patient resistance, are conflicted on their role in addressing tobacco, and lack tobacco training. They suggested strategies at multiple levels that would help overcome those barriers that can be used to design interventions that improve tobacco treatment delivery for mental health patients. IMPLICATIONS: This study builds upon the existing literature on the high rates of smoking, but low rates of treatment, in people with mental health diagnoses. This study is one of the few qualitative evaluations of mental health clinic staff perceptions of barriers and facilitators to treating tobacco. The study results provide a multi-level framework for developing strategies to improve the implementation of tobacco treatment programs in mental health clinics.