Faculty Bibliography

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

Hospital patients with serious mental illness (SMI) have high rates of smoking. There are few post-discharge treatment models available for this population and limited research on their treatment uptake following discharge. This study is a secondary analysis of an RCT that compared multi-session intensive telephone counseling versus referral to state quitline counseling at two safety net hospitals in New York City. For this analysis, we selected all trial participants with a history of schizophrenia, schizoaffective disorder or bipolar disorder (N = 384) and used multivariable logistic regression to compare groups on self-reported 30-day abstinence at 6 months and to identify patient factors associated with use of tobacco treatment. Analyses found no significant group differences in abstinence 6 months (28% quitline vs. 29% intervention, p > 0.05), use of cessation medications (42% quitline vs. 47% intervention, p > 0.05) or receipt of at least one counseling call (47% quitline vs. 42% intervention, p > 0.05). Patients with hazardous drinking (p = 0.04) or perceived good health (p = 0.03) were less likely to use cessation medications. Homeless patients were less likely to use counseling (p = 0.02). Most patients did not use cessation treatment after discharge, and the intensive intervention did not improve abstinence rates over quitline referral. Interventions are needed to improve use of cessation treatment and long-term abstinence in patients with SMI.

STATEMENT OF PROBLEM OR QUESTION (ONE SENTENCE): T2D patients needing insulin adjustments require multiple clinic visits for titration, but face barriers (missed work, transportation costs, clinic co-pays) all of which disproportionately affect vulnerable populations. OBJECTIVES OF PROGRAM/INTERVENTION (NO MORE THAN THREE OBJECTIVES): MITI aims to be clinically efficacious, patientcentered, and highly accessible (only requires text messaging and phone calls). DESCRIPTION OF PROGRAM/INTERVENTION, INCLUDING ORGANIZATIONAL CONTEXT (E.G. INPATIENT VS. OUTPATIENT, PRACTICE OR COMMUNITY CHARACTERISTICS): MITI is an efficacious, patient-centered, accessible program that remotely guides T2D patients to their correct basal insulin dose (glargine, detemir). Eligible patients have T2D, an A1c >8%, a phone that can text, and need titration of basal insulin. Patients referred by their providers are enrolled on a secure website which sends a weekday text message asking 'What was your fasting blood sugar this morning?' Each day the MITI nurse checks the website for alarm values (extreme high or low values). Once a week, the MITI nurse calls patients and, using the MITI titration algorithm, advises them on dose adjustments. The goal of the program is to find the optimal basal insulin dose (OID), which is the dose that achieves a fasting blood sugar between 80 and 130 (or the maximal dose of 50 units). MITI lasts a maximum of 12 weeks. When the program ends, patients return to usual care. MEASURES OF SUCCESS (DISCUSS QUALITATIVE AND/OR QUANTITATIVE METRICS WHICH WILL BE USED TO EVALUATE PROGRAM/INTERVENTION): Using a single-group, quasiexperimental approach, we examined the proportion of patients reaching OID within 12 weeks, the mean number of days required to reach OID, and reductions in fasting glucose and A1c. We described participant response rates, staff time required to deliver the intervention, and patient time saved. Qualitative interviews were also conducted. FINDINGS TO DATE (IT IS NOT SUFFICIENT TOSTATE FINDINGS WILL BE DISCUSSED): Of the 71 participants who completed the program, 86% reached OID, 5.6% did not reach OID, and 8.5% terminated the program early. Those reaching OID did so in a mean of 21 (SD 21) days. Fasting glucose levels decreased from 209 (SD 77) mg/dl to 140 (SD 45), and mean A1c (for those with follow up labs thus far) decreased from 11.6% (SD 1.9) to 10.0% (SD 2.2). Ninety-one percent of text prompts received a response from the participant. Mean staff time required to deliver MITI was 16 min (SD 5) per participant per week, and patients reported a mean time saving of 150 (SD 74) min each time an in-person visit was averted. Qualitative interviews suggest that clinical staff perceived MITI to be a preferred alternative to clinic-based insulin titration, one that resulted in good care without interfering with clinic flow. Patients reported that the enrollment process was easy and that MITI motivated them to eat healthier food, take their insulin, and check their blood sugars. Because of MITI they reported feeling more connected to their medical team. KEYLESSONS FORDISSEMINATION(WHAT CANOTHERS TAKE AWAY FOR IMPLEMENTATION TO THEIR PRACTICE OR COMMUNITY?): MITI is a clinically efficacious, patient-centered and accessible program for the titration of basal insulin for T2D patients. By eliminating the need for in-person access, MITI proves especially helpful for vulnerable populations. Patients and staff found MITI to be convenient, time-saving, and motivating for patients

BACKGROUND: In the Spring and Summer of 2016, a text-messaging intervention to titrate basal insulin in patients with type 2 diabetes and poor glycemic control was implemented at two safety net health care systems in New York City. The goal of the current study was to conduct a qualitative evaluation assessing barriers to, and facilitators of, implementation of the mobile insulin titration intervention (called "MITI"). METHODS: We conducted in-depth qualitative interviews with patients (N = 36) and physician, nursing and administrative staff (N = 19) at the two health care systems implementing MITI. Interviews were transcribed and coded by two study investigators using a codebook guided by the Consolidated Framework for Implementation Research and through iterative, consensus driven content analysis. RESULTS: Patients and staff perceived MITI as convenient and timesaving for patients, easy to use, and effective at achieving its clinical goals. Patients were comfortable sharing health information via text, and felt good about communicating with their health team remotely. Interviewees across stakeholder groups felt that MITI was helpful beyond insulin titration by reminding and motivating patients to engage in healthy behaviors and improving medication adherence. Staff felt MITI worked well with existing workflows and expressed a desire to see MITI expanded to other chronic conditions. Nurses responsible for weekly titration reported initial concerns over safety/liability, time required to deliver the program, difficulties reaching patients for titration calls and the need for ongoing support/training in using the online texting platform. Perceived barriers to MITI implementation reported by providers included perceived lack of patient cell phone access or texting capabilities and patient language barriers. There was also a theme that emerged across interviewees of an unmet need for additional diabetes management support among this population, beyond insulin support provided by MITI. The project team made several modifications to MITI operations in response to these findings. CONCLUSIONS: Patients and staff were overwhelmingly supportive of MITI and believed it had many benefits. Initial implementation of MITI should address nurse comfort, workload and training, and sites should provide ongoing support and training for nurses after implementation. Future research should explore options for integrating additional diabetes support for patients enrolled in MITI or after they are discharged from the program

OBJECTIVE: This study sought to identify rates and predictors of obesity counseling performed by outpatient psychiatrists in the United States. METHODS: The 2005-2010 National Ambulatory Medical Care Surveys provided data from 7,309 outpatient psychiatry visits. Logistic regression was used to examine associations between patient, visit, and practice characteristics and outcomes. RESULTS: Most (81%) visits occurred in a private practice setting. Nine percent (N=657) of visits included measurement of patient body mass index (BMI); 30% of these visits were with patients who met the obesity criterion (BMI >/=30.0 kg/m2). Among visits with obese patients, 16% included exercise counseling, 22% included weight reduction counseling, and 24% included diet or nutrition counseling. Patients with obesity were more likely than patients without obesity to receive diet or nutrition counseling (p<.05) and weight reduction counseling (p<.05), but not exercise counseling. Black patients were significantly less likely to receive any form of counseling (p<.05). CONCLUSIONS: There is a significant need to improve psychiatrists' obesity counseling.

INTRODUCTION: Hospitalization is a unique opportunity for smoking cessation, but prior interventions have measured efficacy with narrowly defined populations. The objective of this study was to enroll smokers admitted to two "safety net" hospitals and compare the effectiveness of two post-discharge cessation interventions. DESIGN: A randomized comparative effectiveness trial was conducted. SETTING/PARTICIPANTS: At two New York City public hospitals, every hospitalized patient identified as a smoker (based on admission records) was approached. Inclusion criteria were: smoked cigarettes in the past 30 days; spoke English, Spanish, or Mandarin; had a U.S. phone number; not discharged to an institution where follow-up or smoking was limited; and not pregnant/breastfeeding. Of 18,797 patients identified as current smokers between July 2011 and April 2014, a total of 3,047 (16%) were discharged before being approached, 3,273 (17%) were not current smokers, 4,026 (21%) had no U.S. phone number, 2,831 (15%) were ineligible for other reasons, and 3,983 (21%) refused participation. In total, 1,618 (9%) participants enrolled in the study. During follow-up, 69% of participants were reached at 2 months and 68% at 6 months. INTERVENTION: At discharge, participants were randomized to multisession telephone counseling from study staff (n=804) or referral to the state quitline for proactive outreach and counseling (n=814). MAIN OUTCOME MEASURES: Self-reported abstinence at 6 months was measured. Analyses were conducted in late 2015. RESULTS: One quarter of participants were homeless or in unstable housing, 60% had a history of substance abuse, 43% reported current hazardous drinking, and half had a psychiatric diagnosis other than substance abuse. At follow-up, the rate of abstinence (30-day point prevalence) was higher in the intensive counseling arm than the quitline arm at 2 months (29.0% vs 20.7%; relative risk=1.40; 95% CI=1.13, 1.73) and 6 months (37.4% vs 31.5%; relative risk=1.19; 95% CI=1.01, 1.40). CONCLUSIONS: Intensive counseling was more effective than referral to the state quitline. Long-term abstinence was excellent in both groups. Many patients were not eligible for enrollment despite minimal exclusion criteria. TRIAL REGISTRATION: This study is registered at www.clinicaltrials.gov NCT01363245.

INTRODUCTION: People with a mental health diagnosis have high rates of tobacco use and encounter limited availability of tobacco treatment targeted to their needs. This study compared the effectiveness of a specialized telephone smoking-cessation intervention developed for mental health patients with standard state quit-line counseling. DESIGN: RCT. SETTING/PARTICIPANTS: The study was conducted at six Veterans Health Administration facilities in the Northeast U.S. Participants were 577 mental health clinic patients referred by their providers for smoking-cessation treatment. INTERVENTION: From 2010 to 2012, the study implemented a telephone program that included patient referral from a mental health provider, mailed cessation medications, and telephone counseling. Participants were randomized to receive a specialized multisession telephone counseling protocol (n=270) or transfer to their state's quit-line for counseling (n=307). MAIN OUTCOME MEASURES: Participants completed telephone surveys at baseline, 2 months, and 6 months. The study's primary outcome was self-reported 30-day abstinence at 6 months. Secondary outcomes were self-reported 30-day abstinence, counseling satisfaction and counseling content at 2 months, and self-reported use of cessation treatment and quit attempts at 6 months. Logistic regression was used to compare treatment groups on outcomes, controlling for baseline cigarettes per day and site. Inverse probability weighting and multiple imputation were used to handle missing abstinence outcomes. Data were analyzed in 2014-2015. RESULTS: At 6 months, participants in the specialized counseling arm were more likely to report 30-day abstinence (26% vs 18%, OR=1.62, 95% CI=1.24, 2.11). There was no significant group difference in abstinence at 2 months (18% vs 14%, OR=1.31, 95% CI=0.49, 3.49). Participants in the specialized arm were more likely to be assisted with developing a quit plan; receive follow-up calls after quitting; and receive counseling on several domains, including motivation, confidence, smoking triggers, coping with urges, and mental health symptoms (all p<0.05). Specialized counseling participants were more satisfied with treatment and more likely to find the counseling useful (p<0.05). CONCLUSIONS: The specialized counseling intervention was more effective at helping patients quit than transfer to a state quit-line. Patients were more satisfied with the specialized counseling program. TRIAL REGISTRATION: This study is registered at www.clinicaltrials.gov NCT00724308.