Publications by authors named "Caroline Richardson"

201 Publications

Do Wearable Activity Trackers Increase Physical Activity Among Cardiac Rehabilitation Participants? A SYSTEMATIC REVIEW AND META-ANALYSIS.

J Cardiopulm Rehabil Prev 2021 Apr 5. Epub 2021 Apr 5.

Departments of Internal Medicine (Drs Ashur and Lewis) and Family Medicine (Drs Sen and Richardson), University of Michigan, Ann Arbor; Division of Cardiovascular Medicine, University of Michigan, Ann Arbor (Dr Cascino); Taubman Health Sciences Library, University of Michigan Library, Ann Arbor (Ms Townsend); Department of Health Behavior, University of Alabama at Birmingham School of Public Health, Birmingham (Dr Pekmezi); and Division of Cardiovascular Disease, Department of Internal Medicine, University of Alabama at Birmingham, Birmingham (Dr Jackson).

Purpose: The objective of this study was to review randomized controlled trials (RCT), which included a wearable activity tracker in an intervention to promote physical activity among cardiac rehabilitation (CR) participants, and to conduct a meta-analysis for the outcomes of step counts and aerobic capacity (V˙O2max).

Methods: Eight databases were searched for RCTs that included an activity tracker, enrolled adults eligible for CR, and reported outcomes of step count or aerobic capacity. Mean differences were calculated for outcomes in the meta-analyses.

Results: Nineteen RCTs with 2429 participants were included in the systematic review and 10 RCTs with 891 participants were included in the meta-analysis. Meta-analysis of three RCTs using a pedometer or accelerometer demonstrated a significant increase in daily step count compared with controls (n = 211, 2587 steps/d [95% CI, 916-5257]; I2 = 74.6% and P = .002). Meta-analysis of three RCTs using a pedometer or accelerometer intervention demonstrated a significant increase in V˙O2max compared with controls (n = 260, 2.6 mL/min/kg [95% CI, 1.6-3.6]; I2 = 0.0% and P < .0001). Meta-analysis of four RCTs using a heart rate monitor demonstrated a significant increase in V˙O2max compared with controls (n = 420, 1.4 mL/min/kg [95% CI, 0.4-2.3]; I2 = 0.0% and P = .006).

Conclusions: Use of activity trackers among CR participants was associated with significant increases in daily step count and aerobic capacity when compared with controls. However, study size was small and variability in intervention supports the need for larger trials to assess use of activity trackers in CR.
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http://dx.doi.org/10.1097/HCR.0000000000000592DOI Listing
April 2021

Association between fasting insulin and C-reactive protein among adults without diabetes using a two-part model: NHANES 2005-2010.

Diabetol Metab Syndr 2021 Mar 10;13(1):29. Epub 2021 Mar 10.

Systems, Populations and Leadership, University of Michigan, Ann Arbor, MI, USA.

Introduction: Chronic inflammation is associated with the development, progression and long-term complications of type 2 diabetes. Hyperglycemia is associated with chronic low-grade inflammation, and thus has become the focus of many screening and treatment recommendations. We hypothesize that insulin may also be associated with inflammation and may be an additional factor to consider in screening and treatment.

Methods: This study used National Health and Nutrition Examination Survey data from 2005 to 2010 to analyze the association between fasting insulin and C-reactive protein (CRP). A two-part model was used due to the high number of values reported as 0.1 mg/L. Two models were analyzed, both with and without the addition of waist circumference to other covariates in the model.

Results: The final sample included 4527 adults with a mean age of 43.31 years. In the first model, higher fasting insulin was associated with increased odds of CRP > 0.1 mg/L (OR = 1.02, p < .001) and with higher CRP (β = 0.03, p < .001). In the adjusted model, including waist circumference as a covariate, higher fasting insulin was not associated with CRP > 0.1 mg/L (OR = 1.00, p = .307) but the association between higher fasting insulin and higher continuous CRP remained significant (β = 0.01, p = .012).

Conclusion: This study found that higher fasting insulin is associated with higher CRP. These results suggest that treatment approaches that simultaneously decrease insulin levels as well as glucose levels may provide additive anti-inflammatory effects, and therefore may improve long-term outcomes for adults with type 2 diabetes.
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http://dx.doi.org/10.1186/s13098-021-00645-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7944601PMC
March 2021

Can Technology-Based Physical Activity Programs for Chronic Obstructive Pulmonary Disease Be Cost-Effective?

Telemed J E Health 2021 Feb 24. Epub 2021 Feb 24.

VA Boston Healthcare System, Boston, Massachusetts, USA.

To evaluate the cost-effectiveness of a technology-based physical activity (PA) intervention for chronic obstructive pulmonary disease (COPD). A secondary data analysis was performed from a randomized controlled trial in COPD of an activity monitor alone or an activity monitor plus a web-based PA intervention. Models estimated cost per quality-adjusted life year (QALY) and incremental cost-effectiveness ratios (ICERs) compared with usual care. The estimated ICER for both groups was below the willingness-to-pay threshold of $50,000/QALY (activity monitor alone = $10,437/QALY; website plus activity monitor intervention = $13,065/QALY). A probabilistic simulation estimated 76% of the activity monitor-alone group and 78% of the intervention group simulations to be cost-effective. Both the activity monitor-alone group and the activity monitor plus website group were cost-effective at the base case by using conventional willingness-to-pay thresholds. Further research would benefit from a more direct estimate of health utilities and downstream health care costs. Clinical Trials.gov NCT01102777.
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http://dx.doi.org/10.1089/tmj.2020.0398DOI Listing
February 2021

Systemic Racism and Health Disparities: A Statement From Editors of Family Medicine Journals.

J Am Board Fam Med 2021 Jan-Feb;34(1):4-5

From the American Family Physician (SMS); Annals of Family Medicine (CRR); FPM (SBS); Journal of the American Board of Family Medicine (MAB); Journal of Family Practice (JH); PRiMER (CPM); FPIN/Evidence-Based Practice (TFM); Canadian Family Physician (NP); Family Medicine (JWS); FP Essentials (DBW).

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http://dx.doi.org/10.3122/jabfm.2021.01.200579DOI Listing
January 2021

Diabetes Distress and Glycemic Control in Type 2 Diabetes: Mediator and Moderator Analysis of a Peer Support Intervention.

JMIR Diabetes 2021 Jan 11;6(1):e21400. Epub 2021 Jan 11.

Ann Arbor Veteran Affairs Hospital, Ann Arbor, MI, United States.

Background: High levels of psychosocial distress are correlated with worse glycemic control as measured by glycosylated hemoglobin levels (HbA). Some interventions specifically targeting diabetes distress have been shown to lead to lower HbA values, but the underlying mechanisms mediating this improvement are unknown. In addition, while type 2 diabetes mellitus (T2D) disproportionately affects low-income racial and ethnic minority populations, it is unclear whether interventions targeting distress are differentially effective depending on participants' baseline characteristics.

Objective: Our objective was to evaluate the mediators and moderators that would inform interventions for improvements in both glycemic control and diabetes distress.

Methods: Our target population included 290 Veterans Affairs patients with T2D enrolled in a comparative effectiveness trial of peer support alone versus technology-enhanced peer support with primary and secondary outcomes including HbA and diabetes distress at 6 months. Participants in both arms had significant improvements in both HbA and diabetes distress at 6 months, so the arms were pooled for all analyses. Goal setting, perceived competence, intrinsic motivation, and decisional conflict were evaluated as possible mediators of improvements in both diabetes distress and HbA. Baseline patient characteristics evaluated as potential moderators included age, race, highest level of education attained, employment status, income, health literacy, duration of diabetes, insulin use, baseline HbA, diabetes-specific social support, and depression.

Results: Among the primarily African American male veterans with T2D, the median age was 63 (SD 10.2) years with a baseline mean HbA of 9.1% (SD 1.7%). Improvements in diabetes distress were correlated with improvements in HbA in both bivariate and multivariable models adjusted for age, race, health literacy, duration of diabetes, and baseline HbA. Improved goal setting and perceived competence were found to mediate both the improvements in diabetes distress and in HbA, together accounting for 20% of the effect of diabetes distress on change in HbA. Race and insulin use were found to be significant moderators of improvements in diabetes distress and improved HbA.

Conclusions: Prior studies have demonstrated that some but not all interventions that improve diabetes distress can lead to improved glycemic control. This study found that both improved goal setting and perceived competence over the course of the peer support intervention mediated both improved diabetes distress and improved HbA. This suggests that future interventions targeting diabetes distress should also incorporate elements to increase goal setting and perceived competence. The intervention effect of improvements in diabetes distress on glycemic control in peer support may be more pronounced among White and insulin-dependent veterans. Additional research is needed to understand how to better target diabetes distress and glycemic control in other vulnerable populations.
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http://dx.doi.org/10.2196/21400DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7834928PMC
January 2021

Impact of patient characteristics and perceived barriers on referral to exercise rehabilitation among patients with pulmonary hypertension in the United States.

Pulm Circ 2020 Oct-Dec;10(4):2045894020974926. Epub 2020 Dec 8.

Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA.

Exercise rehabilitation is underutilized in patients with pulmonary arterial hypertension despite improving exercise capacity and quality of life. We sought to understand the association between (1) patient characteristics and (2) patient-perceived barriers and referral to exercise rehabilitation. We performed a cross-sectional survey of patients with pulmonary arterial hypertension or chronic thromboembolic pulmonary hypertension attending an International PAH meeting. Predictors of referral considered included gender, body mass index, subjective socioeconomic status, insurance type, age, and World Health Organization functional class and perceived barriers assessed using the Cardiac Rehabilitation Barriers Scale. Among 65 participants, those in the lowest subjective socioeconomic status tertile had reduced odds of referral compared to the highest tertile participants (odds ratio 0.22, 95% confidence interval: 0.05-0.98,  = 0.047). Several patient-perceived barriers were associated with reduced odds of referral. For every 1-unit increase in a reported barrier on a five-point Likert scale, odds of referral were reduced by 85% for my doctor did not feel it was necessary; 85% for prefer to take care of my health alone, not in a group; 78% many people with heart and lung problems don't go, and they are fine; and 78% for I didn't know about exercise therapy. The lack of perceived need subscale and overall barriers score were associated with a 92% and 77% reduced odds of referral, respectively. These data suggest the need to explore interventions to promote referral among low socioeconomic status patients and address perceived need for the therapy.
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http://dx.doi.org/10.1177/2045894020974926DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7731716PMC
December 2020

Continuous Glucose Monitoring With Low-Carbohydrate Diet Coaching in Adults With Prediabetes: Mixed Methods Pilot Study.

JMIR Diabetes 2020 Dec 16;5(4):e21551. Epub 2020 Dec 16.

Department of Family Medicine, University of Michigan, Ann Arbor, MI, United States.

Background: Type 2 diabetes mellitus (T2DM) is preventable; however, few patients with prediabetes participate in prevention programs. The use of user-friendly continuous glucose monitors (CGMs) with low-carbohydrate diet coaching is a novel strategy to prevent T2DM.

Objective: This study aims to determine the patient satisfaction and feasibility of an intervention combining CGM use and low-carbohydrate diet coaching in patients with prediabetes to drive dietary behavior change.

Methods: We conducted a mixed methods, single-arm pilot and feasibility study at a suburban family medicine clinic. A total of 15 adults with prediabetes with hemoglobin A (HbA) levels between 5.7% and 6.4% and a BMI >30 kg/m were recruited to participate. The intervention and assessments took place during 3 in-person study visits and 2 qualitative phone interviews (3 weeks and 6 months after the intervention). During visit 1, participants were asked to wear a CGM and complete a food intake and craving log for 10 days. During visit 2, the food intake and craving log along with the CGM results of the participants were reviewed and the participants received low-carbohydrate diet coaching, including learning about carbohydrates and personalized feedback. A second CGM sensor, with the ability to scan and record glucose trends, was placed, and the participants logged their food intake and cravings as they attempted to reduce their total carbohydrate intake (<100 g/day). During visit 3, the participants reviewed their CGM and log data. The primary outcome was satisfaction with the use of CGM and low-carbohydrate diet. The secondary outcomes included feasibility, weight, and HbA change, and percentage of time spent in hyperglycemia. Changes in attitudes and risk perception of developing diabetes were also assessed.

Results: The overall satisfaction rate of our intervention was 93%. The intervention induced a weight reduction of 1.4 lb (P=.02) and a reduction of HbA levels by 0.71% (P<.001) since enrollment. Although not significantly, the percentage of time above glucose goal and average daily glucose levels decreased slightly during the study period. Qualitative interview themes indicated no major barriers to CGM use; the acceptance of a low-carbohydrate diet; and that CGMs helped to visualize the impact of carbohydrates on the body, driving dietary changes.

Conclusions: The use of CGMs and low-carbohydrate diet coaching to drive dietary changes in patients with prediabetes is feasible and acceptable to patients. This novel method merits further exploration, as the preliminary data indicate that combining CGM use with low-carbohydrate diet coaching drives dietary changes, which may ultimately prevent T2DM.
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http://dx.doi.org/10.2196/21551DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7773517PMC
December 2020

Insurance Coverage and Use of Hormones Among Transgender Respondents to a National Survey.

Ann Fam Med 2020 11;18(6):528-534

Institute for Healthcare Policy & Innovation, University of Michigan, Ann Arbor, Michigan.

Purpose: We undertook a study to assess the associations between barriers to insurance coverage for gender-affirming hormones (either lack of insurance or claim denial) and patterns of hormone use among transgender adults.

Methods: We used data from the US Transgender Survey, a large national sample of 27,715 transgender adults, collected from August to September 2015. We calculated weighted proportions and performed multivariate logistic regression analyses.

Results: Of 12,037 transgender adults using hormones, 992 (9.17%) were using nonprescription hormones. Among insured respondents, 2,528 (20.81%) reported that their claims were denied. Use of nonprescription hormones was more common among respondents who were uninsured (odds ratio = 2.64; 95% CI, 1.88-3.71; <.001) or whose claims were denied (odds ratio = 2.53; 95% CI, 1.61-3.97; <.001). Uninsured respondents were also less likely to be using hormones (odds ratio = 0.37; 95% CI, 0.24-0.56; <.001).

Conclusions: Lack of insurance coverage for gender-affirming hormones is associated with lower overall odds of hormone use and higher odds of use of nonprescription hormones; such barriers may thus be linked to unmonitored and unsafe medication use, and increase the risks for adverse health outcomes. Ensuring access to hormones can decrease the economic burden transgender people face, and is an important part of harm-reduction strategies.
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http://dx.doi.org/10.1370/afm.2586DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7708284PMC
November 2020

Development and implementation of a community health centre-based cooking skills intervention in Detroit, MI.

Public Health Nutr 2021 Feb 30;24(3):549-560. Epub 2020 Sep 30.

Department of Nutritional Sciences, University of Michigan School of Public Health, Ann Arbor, MI, USA.

Objective: To develop and implement a community-tailored, food agency-based cooking programme at a community health centre (CHC) and evaluate the effect of the intervention on cooking confidence and food waste.

Design: This study used an exploratory, sequential mixed methods design. Focus groups (n 38) were conducted to inform the development of a cooking intervention, then six cooking classes (n 45) were planned and piloted in the health centre's teaching kitchen. Changes in cooking confidence and related outcomes were assessed using pre- and post-class surveys. Follow-up interviews (n 12) were conducted 2-4 months post-intervention to assess satisfaction and short-term outcomes.

Setting: A CHC in Detroit, MI.

Participants: Spanish- and English-speaking adults aged ≥18 years recruited at the CHC.

Results: In the formative focus groups, patients identified multiple barriers to cooking healthy meals, including trade-offs between quality, cost and convenience of food, chronic disease management and lack of time and interest. Each cooking class introduced a variety of cooking techniques and food preservation strategies. Participants demonstrated increased confidence in cooking (P 0·004), experimenting with new ingredients (P 0·006) and knowing how to make use of food before it goes bad (P 0·017). In post-class interviews, participants reported that they valued the social interaction and participatory format and that they had used the recipes and cooking techniques at home.

Conclusions: A community-tailored, hands-on cooking class was an effective way to engage patients at a CHC and resulted in increased cooking confidence.
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http://dx.doi.org/10.1017/S1368980020003481DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7854932PMC
February 2021

Age and Attitudes Towards an Internet-Mediated, Pedometer-Based Physical Activity Intervention for Chronic Obstructive Pulmonary Disease: Secondary Analysis.

JMIR Aging 2020 Sep 9;3(2):e19527. Epub 2020 Sep 9.

Pulmonary and Critical Care Medicine Section, Veterans Affairs Boston Healthcare System, Boston, MA, United States.

Background: Chronic obstructive pulmonary disease (COPD) is prevalent among older adults. Promoting physical activity and increasing exercise capacity are recommended for all individuals with COPD. Pulmonary rehabilitation is the standard of care to improve exercise capacity, although there are barriers that hinder accessibility. Technology has the potential to overcome some of these barriers, but it is unclear how aging adults with a chronic disease like COPD perceive technology-based platforms to support their disease self-management.

Objective: Guided by the unified theory of acceptance and use of technology, the current retrospective secondary analysis explores if age moderates multiple factors that influence an individual with COPD's openness toward an internet-mediated, pedometer-based physical activity intervention.

Methods: As part of an efficacy study, participants with COPD (N=59) were randomly assigned to use an internet-mediated, pedometer-based physical activity intervention for 12 weeks. At completion, they were asked about their experience with the intervention using a survey, including their performance expectancy and effort expectancy, facilitating conditions (ie, internet use frequency and ability), and use of the intervention technology. Logistic regression and general linear modeling examined the associations between age and these factors.

Results: Participants ranged in age from 49 to 89 years (mean 68.66, SD 8.93). Disease severity was measured by forced expiratory volume in the first second percent predicted (mean 60.01, SD 20.86). Nearly all participants (54/59) believed the intervention was useful. Regarding effort expectancy, increasing age was associated with reporting that it was easy to find the time to engage in the intervention. Regarding facilitating conditions, approximately half of the participants believed the automated step count goals were too high (23/59) and many did not feel comfortable reaching their goals (22/59). The probability of these perceptions increased with age, even after accounting for disease severity. Age was not associated with other facilitating conditions or use of the technology.

Conclusions: Age does not influence performance expectancy or use of technology with an internet-mediated, pedometer-based physical activity intervention. Age is associated with certain expectations of effort and facilitating conditions. Consideration of age of the user is needed when personalizing step count goals and time needed to log in to the website.

Trial Registration: ClinicalTrials.gov NCT01772082; https://clinicaltrials.gov/ct2/show/NCT01772082.
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http://dx.doi.org/10.2196/19527DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7511871PMC
September 2020

Understanding the Feasibility, Acceptability, and Efficacy of a Clinical Pharmacist-led Mobile Approach (BPTrack) to Hypertension Management: Mixed Methods Pilot Study.

J Med Internet Res 2020 08 11;22(8):e19882. Epub 2020 Aug 11.

Department of Family Medicine, University of Michigan, Ann Arbor, MI, United States.

Background: Hypertension is a prevalent and costly burden in the United States. Clinical pharmacists within care teams provide effective management of hypertension, as does home blood pressure monitoring; however, concerns about data quality and latency are widespread. One approach to close the gap between clinical pharmacist intervention and home blood pressure monitoring is the use of mobile health (mHealth) technology.

Objective: We sought to investigate the feasibility, acceptability, and preliminary effectiveness of BPTrack, a clinical pharmacist-led intervention that incorporates patient- and clinician-facing apps to make electronically collected, patient-generated data available to providers in real time for hypertension management. The patient app also included customizable daily medication reminders and educational messages. Additionally, this study sought to understand barriers to adoption and areas for improvement identified by key stakeholders, so more widespread use of such interventions may be achieved.

Methods: We conducted a mixed methods pilot study of BPTrack, to improve blood pressure control in patients with uncontrolled hypertension through a 12-week pre-post intervention. All patients were recruited from a primary care setting where they worked with a clinical pharmacist for hypertension management. Participants completed a baseline visit, then spent 12 weeks utilizing BPTrack before returning to the clinic for follow-up. Collected data from patient participants included surveys pre- and postintervention, clinical measures (for establishing effectiveness, with the primary outcome being a change in blood pressure and the secondary outcome being a change in medication adherence), utilization of the BPTrack app, interviews at follow-up, and chart review. We also conducted interviews with key stakeholders.

Results: A total of 15 patient participants were included (13 remained through follow-up for an 86.7% retention rate) in a single group, pre-post assessment pilot study. Data supported the hypothesis that BPTrack was feasible and acceptable for use by patient and provider participants and was effective at reducing patient blood pressure. At the 12-week follow-up, patients exhibited significant reductions in both systolic blood pressure (baseline mean 137.3 mm Hg, SD 11.1 mm Hg; follow-up mean 131.0 mm Hg, SD 9.9 mm Hg; P=.02) and diastolic blood pressure (baseline mean 89.4 mm Hg, SD 7.7 mm Hg; follow-up mean 82.5 mm Hg, SD 8.2 mm Hg; P<.001). On average, patients uploaded at least one blood pressure measurement on 75% (SD 25%) of study days. No improvements in medication adherence were noted. Interview data revealed areas of improvement and refinement for the patient experience. Furthermore, stakeholders require integration into the electronic health record and a modified clinical workflow for BPTrack to be truly useful; however, both patients and stakeholders perceived benefits of BPTrack when used within the context of a clinical relationship.

Conclusions: Results demonstrate that a pharmacist-led mHealth intervention promoting home blood pressure monitoring and clinical pharmacist management of hypertension can be effective at reducing blood pressure in primary care patients with uncontrolled hypertension. Our data also support the feasibility and acceptability of these types of interventions for patients and providers.

Trial Registration: ClinicalTrials.gov NCT02898584; https://clinicaltrials.gov/ct2/show/NCT02898584.

International Registered Report Identifier (irrid): RR2-10.2196/resprot.8059.
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http://dx.doi.org/10.2196/19882DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7448180PMC
August 2020

Effect of Adding Telephone-Based Brief Coaching to an mHealth App (Stay Strong) for Promoting Physical Activity Among Veterans: Randomized Controlled Trial.

J Med Internet Res 2020 08 4;22(8):e19216. Epub 2020 Aug 4.

Veterans Affairs Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, United States.

Background: Though maintaining physical conditioning and a healthy weight are requirements of active military duty, many US veterans lose conditioning and rapidly gain weight after discharge from active duty service. Mobile health (mHealth) interventions using wearable devices are appealing to users and can be effective especially with personalized coaching support. We developed Stay Strong, a mobile app tailored to US veterans, to promote physical activity using a wrist-worn physical activity tracker, a Bluetooth-enabled scale, and an app-based dashboard. We tested whether adding personalized coaching components (Stay Strong+Coaching) would improve physical activity compared to Stay Strong alone.

Objective: The goal of this study is to compare 12-month outcomes from Stay Strong alone versus Stay Strong+Coaching.

Methods: Participants (n=357) were recruited from a national random sample of US veterans of recent wars and randomly assigned to the Stay Strong app alone (n=179) or Stay Strong+Coaching (n=178); both programs lasted 12 months. Personalized coaching components for Stay Strong+Coaching comprised of automated in-app motivational messages (3 per week), telephone-based human health coaching (up to 3 calls), and personalized weekly goal setting. All aspects of the enrollment process and program delivery were accomplished virtually for both groups, except for the telephone-based coaching. The primary outcome was change in physical activity at 12 months postbaseline, measured by average weekly Active Minutes, captured by the Fitbit Charge 2 device. Secondary outcomes included changes in step counts, weight, and patient activation.

Results: The average age of participants was 39.8 (SD 8.7) years, and 25.2% (90/357) were female. Active Minutes decreased from baseline to 12 months for both groups (P<.001) with no between-group differences at 6 months (P=.82) or 12 months (P=.98). However, at 12 months, many participants in both groups did not record Active Minutes, leading to missing data in 67.0% (120/179) for Stay Strong and 61.8% (110/178) for Stay Strong+Coaching. Average baseline weight for participants in Stay Strong and Stay Strong+Coaching was 214 lbs and 198 lbs, respectively, with no difference at baseline (P=.54) or at 6 months (P=.28) or 12 months (P=.18) postbaseline based on administrative weights, which had lower rates of missing data. Changes in the number of steps recorded and patient activation also did not differ by arm.

Conclusions: Adding personalized health coaching comprised of in-app automated messages, up to 3 coaching calls, plus automated weekly personalized goals, did not improve levels of physical activity compared to using a smartphone app alone. Physical activity in both groups decreased over time. Sustaining long-term adherence and engagement in this mHealth intervention proved difficult; approximately two-thirds of the trial's 357 participants failed to sync their Fitbit device at 12 months and, thus, were lost to follow-up.

Trial Registration: ClinicalTrials.gov NCT02360293; https://clinicaltrials.gov/ct2/show/NCT02360293.

International Registered Report Identifier (irrid): RR2-10.2196/12526.
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http://dx.doi.org/10.2196/19216DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7435619PMC
August 2020

Focus on Systems to Improve Morbidity and Mortality Conference Relevance.

Fam Med 2020 06;52(7):528-532

University of Michigan Medical School, Ann Arbor, MI.

Background And Objectives: Morbidity and mortality conference (MMC) is educationally important. However, resident physicians rate it less positively than faculty, citing focus on assigning blame rather than targeting change. Additionally, many MMC presentations are selected for clinical novelty instead of avoidable outcome. Despite significant time and resources routinely committed to MMC, its educational and clinical impact is generally limited. This warrants shifting focus toward quality improvement and systems-based care.

Methods: From July to December 2017, within a large, public academic center and medical school, the family medicine MMC became a quality conference (QC) focusing on thematically-linked, system-based errors. After case presentations, the audience split into small groups for targeted discussion then reconvened to identify specific interventions. We collected attitudinal data from faculty and resident physicians in attendance using real-time audience text polling, targeting case relevance and change impact.

Results: Compared to MMC, QC case relevance improved by 0.39 (P<.01) on a 5-point scale. Compared to MMC, QC cumulatively approached but did not meet statistical significance regarding changing clinical practice. Qualitative statements commented on increased multilevel engagement, dedicated follow up, and decreased didactic presentations.

Conclusions: QC demonstrated statistically significant increased relevance compared to MMC, reflecting the benefit of systems-based, thematically-linked cases.
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http://dx.doi.org/10.22454/FamMed.2020.940516DOI Listing
June 2020

Study protocol: Using peer support to aid in prevention and treatment in prediabetes (UPSTART).

Contemp Clin Trials 2020 08 1;95:106048. Epub 2020 Jun 1.

Kaiser Permanente Northern California Division of Research, United States of America. Electronic address:

Background: There is an urgent need to develop and evaluate effective and scalable interventions to prevent or delay the onset of type 2 diabetes mellitus (T2DM).

Methods: In this randomized controlled pragmatic trial, 296 adults with prediabetes will be randomized to either a peer support arm or enhanced usual care. Participants in the peer support arm meet face-to-face initially with a trained peer coach who also is a patient at the same health center to receive information on locally available wellness and diabetes prevention programs, discuss behavioral goals related to diabetes prevention, and develop an action plan for the next week to meet their goals. Over six months, peer coaches call their assigned participants weekly to provide support for weekly action steps. In the final 6 months, coaches call participants at least once monthly. Participants in the enhanced usual care arm receive information on local resources and periodic updates on available diabetes prevention programs and resources. Changes in A1c, weight, waist circumference and other patient-centered outcomes and mediators and moderators of intervention effects will be assessed.

Results: At least 296 participants and approximately 75 peer supporters will be enrolled.

Discussion: Despite evidence that healthy lifestyle interventions can improve health behaviors and reduce risk for T2DM, engagement in recommended behavior change is low. This is especially true among racial and ethnic minority and low-income adults. Regular outreach and ongoing support from a peer coach may help participants to initiate and sustain healthy behavior changes to reduce their risk of diabetes.

Trial Registration: The ClinicalTrials.gov registration number is NCT03689530.
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http://dx.doi.org/10.1016/j.cct.2020.106048DOI Listing
August 2020

Availability of Sexually Transmitted Infection Screening and Expedited Partner Therapy at Federally Qualified Health Centers in Michigan.

Sex Transm Dis 2020 07;47(7):437-440

From the Department of Family Medicine, University of Michigan Institute for Healthcare Policy and Innovation affiliation to Okeoma Mmeje.

Via secret shopper study, we assessed: (1) availability of sexually transmitted infection (STI) screening; (2) provision of expedited partner therapy; and (3) wait times for new patient STI screening appointments at Michigan federally qualified health centers. Of the 147 clinics with STI screening availability, 10.2% (15) confirmed expedited partner therapy provision.
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http://dx.doi.org/10.1097/OLQ.0000000000001190DOI Listing
July 2020

Physicians' Perceptions of Proton Pump Inhibitor Risks and Recommendations to Discontinue: A National Survey.

Am J Gastroenterol 2020 05;115(5):689-696

Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA.

Objective: To provide contemporary estimates of internists' perceptions of adverse effects associated with proton pump inhibitors (PPIs) and self-reported clinical use.

Methods: We invited 799 internists, including specialists and postgraduate trainees, to complete an online survey. Topics included perceptions of PPI adverse effects (AEs) and effectiveness for upper gastrointestinal bleeding (UGIB) prevention, changes in prescribing, and management recommendations for patients using PPIs for gastroesophageal reflux disease or UGIB prevention. We used logistic regression to identify factors associated with appropriate PPI continuation in the scenario of a patient at high risk for UGIB.

Results: Among 437 respondents (55% response rate), 10% were trainees and 72% specialized in general medicine, 70% were somewhat/very concerned about PPI AEs, and 76% had somewhat/very much changed their prescribing. A majority believed PPIs increase the risk for 6 of 12 AEs queried. Fifty-two percent perceived PPIs to be somewhat/very effective for UGIB prevention. In a gastroesophageal reflux disease scenario in which PPI can be safely discontinued, 86% appropriately recommended PPI discontinuation. However, in a high-risk UGIB prevention scenario in which long-term PPI use is recommended, 79% inappropriately recommended discontinuation. In this latter scenario, perceived effectiveness for bleeding prevention was strongly associated with continuing PPI (odds ratio 7.68, P < 0.001 for moderately; odds ratio 17.3, P < 0.001 for very effective). Other covariates, including concern about PPI AEs, had no significant association.

Discussion: Most internists believe PPIs cause multiple AEs and recommend discontinuation even in patients at high risk for UGIB. Future interventions should focus on ensuring that PPIs are prescribed appropriately according to individual risks and benefits.
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http://dx.doi.org/10.14309/ajg.0000000000000558DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7196016PMC
May 2020

Long-term effects of web-based pedometer-mediated intervention on COPD exacerbations.

Respir Med 2020 02 11;162:105878. Epub 2020 Jan 11.

Pulmonary and Critical Care Medicine Section, VA Boston Healthcare System, Boston, MA, USA; Harvard Medical School, Boston, MA, USA. Electronic address:

Background: Technology-based physical activity (PA) interventions have been shown to improve daily step counts and health-related quality of life, but their effect on long-term clinical outcomes like acute exacerbations (AEs) is unknown in persons with COPD.

Methods: U.S. Veterans with stable COPD were randomized (1:1) to either pedometer alone (control) or pedometer plus a website with feedback, goal-setting, disease education, and a community forum (intervention) for 3 months. AEs were assessed every 3 months over a follow-up period of approximately 15 months. Pedometer-assessed daily step counts, health-related quality-of-life (HRQL), and self-efficacy were assessed at baseline, end-of-intervention at 3 months, and during follow-up approximately 6 and 12 months after enrollment. Zero-inflated Poisson models assessed the effect of the intervention on risk for AEs, compared to controls. Generalized linear mixed-effects models for repeated measures examined between-group and within-group changes in daily step count, HRQL, and self-efficacy.

Results: There were no significant differences in age, FEV% predicted, baseline daily step count, AEs the year prior to enrollment, or duration of follow-up between the intervention (n = 57) and control (n = 52) groups. The intervention group had a significantly reduced risk of AEs (rate ratio = 0.51, [95%CI 0.31-0.85]), compared to the control group. There were no significant between-group differences in change in average daily step count, HRQL, or self-efficacy at 6 and 12 months after enrollment.

Conclusions: A 3-month internet-mediated, pedometer-based PA intervention was associated with reduced risk for AEs of COPD over 12-15 months of follow-up. ClinicalTrials.gov identifier: NCT01772082.
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http://dx.doi.org/10.1016/j.rmed.2020.105878DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7269114PMC
February 2020

Mixed methods pilot study of a low-carbohydrate diabetes prevention programme among adults with pre-diabetes in the USA.

BMJ Open 2020 01 21;10(1):e033397. Epub 2020 Jan 21.

University of Michigan Medical School, Ann Arbor, Michigan, USA.

Objectives: (1) To estimate weight change from a low-carbohydrate diabetes prevention programme (LC-DPP) and (2) to evaluate the feasibility and acceptability of an LC-DPP.

Research Design: Single-arm, mixed methods (ie, integration of quantitative and qualitative data) pilot study.

Setting: Primary care clinic within a large academic medical centre in the USA.

Participants: Adults with pre-diabetes and Body Mass Index of ≥25 kg/m.

Intervention: We adapted the Centers for Disease Control and Prevention's National Diabetes Prevention Program (NDPP)-an evidence-based, low-fat dietary intervention-to teach participants to follow a very low-carbohydrate diet (VLCD). Participants attended 23 group-based classes over 1 year.

Outcome Measures: Primary outcome measures were (1) weight change and (2) percentage of participants who achieved ≥5% wt loss. Secondary outcome measures included intervention feasibility and acceptability (eg, attendance and qualitative interview feedback).

Results: Our enrolment target was 22. One person dropped out before a baseline weight was obtained; data from 21 individuals were analysed. Mean weight loss in kilogram was 4.3 (SD 4.8) at 6 months and 4.9 (SD 5.8) at 12 months. Mean per cent body weight changes were 4.5 (SD 5.0) at 6 months and 5.2 (SD 6.0) at 12 months; 8/21 individuals (38%) achieved ≥5% wt loss at 12 months. Mean attendance was 10.3/16 weekly sessions and 3.4/7 biweekly or monthly sessions. Among interviewees (n=14), three factors facilitated VLCD adherence: (1) enjoyment of low-carbohydrate foods, (2) diminished hunger and cravings and (3) health benefits beyond weight loss. Three factors hindered VLCD adherence: (1) enjoyment of high-carbohydrate foods, (2) lack of social support and (3) difficulty preplanning meals.

Conclusions: An LC-DPP is feasible, acceptable and may be an effective option to help individuals with pre-diabetes to lose weight. Data from this pilot will be used to plan a fully powered randomised controlled trial of weight loss among NDPP versus LC-DPP participants.

Trial Registration Number: NCT03258918.
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http://dx.doi.org/10.1136/bmjopen-2019-033397DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7045213PMC
January 2020

More frequent cooking at home is associated with higher Healthy Eating Index-2015 score.

Public Health Nutr 2020 09 10;23(13):2384-2394. Epub 2020 Jan 10.

University of Michigan School of Medicine, Department of Family Medicine, Ann Arbor, MI, USA.

Objective: To examine the association between cooking frequency and Healthy Eating Index (HEI)-2015, overall and by income, among US adults.

Design: Cross-sectional analysis using multivariable linear regression models to examine the association between cooking frequency and total HEI-2015 score adjusted for sociodemographic variables, overall and stratified by income.

Setting: Nationally representative survey data from the USA.

Participants: Adults aged ≥20 years (with 2 d of 24 h dietary recall data) obtained from the 2007 to 2010 National Health and Nutrition Examination Survey (n 8668).

Results: Compared with cooking dinner 0-2 times/week, greater cooking frequency was associated with higher HEI-2015 score overall (≥7 times/week: +3·57 points, P < 0·001), among lower-income adults (≥7 times/week: +2·55 points, P = 0·001) and among higher-income adults (≥7 times/week: +5·07 points, P < 0·001). Overall, total HEI-2015 score was higher among adults living in households where dinner was cooked ≥7 times/week (54·54 points) compared with adults living in households where dinner was cooked 0-2 times/week (50·57 points). In households in which dinner was cooked ≥7 times/week, total HEI-2015 score differed significantly based on income status (lower-income: 52·51 points; higher-income: 57·35 points; P = 0·003). Cooking frequency was associated with significant differences in HEI-2015 component scores, but associations varied by income.

Conclusions: More frequent cooking at home is associated with better diet quality overall and among lower- and higher-income adults, although the association between cooking and better diet quality is stronger among high-income adults. Strategies are needed to help lower-income Americans consume a healthy diet regardless of how frequently they cook at home.
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http://dx.doi.org/10.1017/S1368980019003549DOI Listing
September 2020

Anti-Hypertensive Medication Combinations in the United States.

J Am Board Fam Med 2020 Jan-Feb;33(1):143-146

From the Grant Family Medicine, OhioHealth, Columbus, OH (MEJ, JMG); Heritage College of Osteopathic Medicine at Ohio University, Dublin, OH (MEJ); Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC (JY); Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC (JY); Department of Internal Medicine, Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL (EAJ); Department of Family Medicine, University of Michigan, Ann Arbor, MI (CRR).

Background: Examining the anti-hypertensive regimens of individuals with different comorbidities may offer insights into how we can improve hypertension management.

Methods: The Medical Expenditure Panel Survey (2013-2015) was used to describe the most common single-, two-, three-, and four-drug hypertension regimens among hypertensive adults in four different comorbidity groups: 1. Hypertension only; 2. Hypertension and diabetes; 3. Hypertension and cardiovascular disease (coronary heart disease or stroke history); and 4. Hypertension, diabetes, and cardiovascular disease.

Results: 15,901 adults with hypertension taking anti-hypertensive medications were included in the study. 58.6% (95% CI: 57.3-59.8) took multiple anti-hypertensive medications, but the proportion of adults taking multiple anti-hypertensives varied by comorbidity group. Regimens including an ACE-inhibitor/ARB were the most prevalent regimens among individuals taking ≥2 anti-hypertensive medications. The most common two-drug regimen for both the hypertension-only and hypertension-diabetes groups was an ACE-inhibitor/ARB with thiazide. The most prevalent regimen for the two cardiovascular disease groups was an ACE-inhibitor/ARB with beta-blocker.

Conclusions: Most individuals with hypertension use between 2-5 medications and the medications comprising these regimens vary by comorbidity. The ACCOMPLISH trial suggested that certain combinations may lead to superior cardiovascular outcomes. Research comparing the efficacy of different hypertension medication combinations among individuals with different comorbidities could lead to better patient hypertensionrelated outcomes.
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http://dx.doi.org/10.3122/jabfm.2020.01.190134DOI Listing
April 2021

The Diabetes Prevention Program for Underserved Populations: A Brief Review of Strategies in the Real World.

Diabetes Spectr 2019 Nov;32(4):312-317

VA Ann Arbor Healthcare System, Center for Clinical Management Research, Ann Arbor, MI.

This review highlights examples of the translation of the Diabetes Prevention Program (DPP) to underserved populations. Here, underserved populations are defined as groups whose members are at greater risk for health conditions such as diabetes but often face barriers accessing treatment. Strategies to develop and evaluate future DPP translations are discussed.
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http://dx.doi.org/10.2337/ds19-0007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6858084PMC
November 2019

The Ecology of Medical Care Before and After the Affordable Care Act: Trends From 2002 to 2016.

Ann Fam Med 2019 11;17(6):526-537

Department of Family Medicine, University of Michigan, Ann Arbor, Michigan.

Background: The initial ecology of medical care study was published in 1961, offering a framework by which to investigate individuals' contact with the medical system. We studied changes in the framework around the implementation of the Patient Protection and Affordable Care Act (ACA) within longer-term trends.

Methods: The 2002-2016 Medical Expenditure Panel Survey was used to determine rates of visit/contact per 1,000 individuals per month for physicians, primary care physicians, specialty physicians, emergency departments, inpatient hospitalizations, dental visits, and home health visits for the overall population and by age group, poverty category, health status, and race/ethnicity. Adjusted Wald tests were used to investigate differences between the pre-ACA (2012-2013) and post-ACA (2014-2015) periods. Multivariable linear regression was used to determine trends over the study period (2002-2016).

Results: The survey included 525,804 person-years. The uninsured rate decreased from 12.8% (95% CI, 12.0%-13.7%) in 2013 to 7.6% (95% CI, 7.0%-8.3%) in 2016. From 2002 to 2016, the numbers of individuals in a month who had contact with primary care physicians, dental care, and inpatient hospitalizations decreased. Primary care physician contact decreased most among the elderly and those reporting fair/poor health. After ACA implementation, few significant changes were identified in the overall population or by age, poverty category, race/ethnicity, or health status.

Conclusions: The medical ecology framework was not notably altered 2 years after implementation of the ACA. The long-term decrease in primary care contact does not appear to have been interrupted after implementation of the ACA, was observed across income and age categories, and was most evident among the elderly and individuals reporting fair/poor health.
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http://dx.doi.org/10.1370/afm.2462DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6846273PMC
November 2019

Psychosocial information use for clinical decisions in diabetes care.

J Am Med Inform Assoc 2019 08;26(8-9):813-824

School of Information, School of Public Health, University of Michigan, Ann Arbor, Michigan USA.

Objective: There are increasing efforts to capture psychosocial information in outpatient care in order to enhance health equity. To advance clinical decision support systems (CDSS), this study investigated which psychosocial information clinicians value, who values it, and when and how clinicians use this information for clinical decision-making in outpatient type 2 diabetes care.

Materials And Methods: This mixed methods study involved physician interviews (n = 17) and a survey of physicians, nurse practitioners (NPs), and diabetes educators (n = 198). We used the grounded theory approach to analyze interview data and descriptive statistics and tests of difference by clinician type for survey data.

Results: Participants viewed financial strain, mental health status, and life stressors as most important. NPs and diabetes educators perceived psychosocial information to be more important, and used it significantly more often for 1 decision, than did physicians. While some clinicians always used psychosocial information, others did so when patients were not doing well. Physicians used psychosocial information to judge patient capabilities, understanding, and needs; this informed assessment of the risks and the feasibility of options and patient needs. These assessments influenced 4 key clinical decisions.

Discussion: Triggers for psychosocially informed CDSS should include psychosocial screening results, new or newly diagnosed patients, and changes in patient status. CDSS should support cost-sensitive medication prescribing, and psychosocially based assessment of hypoglycemia risk. Electronic health records should capture rationales for care that do not conform to guidelines for panel management. NPs and diabetes educators are key stakeholders in psychosocially informed CDSS.

Conclusion: Findings highlight opportunities for psychosocially informed CDSS-a vital next step for improving health equity.
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http://dx.doi.org/10.1093/jamia/ocz053DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7647218PMC
August 2019