Publications by authors named "Ranak Trivedi"

69 Publications

Supporting Indian and other South Asians facing COVID-19 and other serious illnesses.

J Pain Symptom Manage 2021 Jul 13. Epub 2021 Jul 13.

Center for Innovation to Implementation, VA Palo Alto Health Care System; Section of Palliative Care, Division of Primary Care and Population Health, Stanford University.

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http://dx.doi.org/10.1016/j.jpainsymman.2021.06.024DOI Listing
July 2021

Impact of a Dyadic Intervention on Family Supporter Involvement in Helping Adults Manage Type 2 Diabetes.

J Gen Intern Med 2021 Jul 8. Epub 2021 Jul 8.

VA Pittsburgh Center for Health Equity Research and Promotion, Pittsburgh, PA, USA.

Background: Family support for adults' diabetes care is associated with improved self-management and outcomes, but healthcare providers lack structured ways to engage those supporters.

Objective: Assess the impact of a patient-supporter diabetes management intervention on supporters' engagement in patients' diabetes care, support techniques, and caregiving experience.

Design: Multivariate regression models examined between-group differences in support-related measures observed as part of a larger trial randomizing participants to a dyadic intervention versus usual care.

Participants: A total of 239 adults with type 2 diabetes and either A1c >8% or systolic blood pressure >160mmHg enrolled with a family supporter.

Intervention: Health coaches provided training on positive support techniques and facilitated self-management information sharing and goal-setting.

Main Measures: Patient and supporter reports at baseline and 12 months of supporter roles in diabetes care and caregiving experience.

Results: At 12 months, intervention-assigned patients had higher odds of reporting increased supporter involvement in remembering medical appointments (AOR 2.74, 95% CI 1.44, 5.21), performing home testing (AOR 2.40, 95% CI 1.29, 4.46), accessing online portals (AOR 2.34, 95% CI 1.29, 4.30), deciding when to contact healthcare providers (AOR 2.12, 95% CI 1.15, 3.91), and refilling medications (AOR 2.10, 95% CI 1.14, 3.89), but not with attending medical appointments or with healthy eating and exercise. Intervention-assigned patients reported increased supporter use of autonomy supportive communication (+0.27 points on a 7-point scale, p=0.02) and goal-setting techniques (+0.30 points on a 5-point scale, p=0.01). There were no differences at 12 months in change scores measuring supporter distress about patients' diabetes or caregiving burden. Intervention-assigned supporters had significantly larger increases in satisfaction with health system support for their role (+0.88 points on a 10-point scale, p=0.01).

Conclusions: A dyadic patient-supporter intervention led to increased family supporter involvement in diabetes self-management and increased use of positive support techniques, without increasing caregiver stress.
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http://dx.doi.org/10.1007/s11606-021-06946-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8266295PMC
July 2021

Caregiver Experiences and Roles in Care Seeking During COPD Exacerbations: A Qualitative Study.

Ann Behav Med 2021 Jun 24. Epub 2021 Jun 24.

Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, USA.

Background: Chronic obstructive pulmonary disease (COPD) is a progressive, debilitating illness characterized by exacerbations that require timely intervention. COPD patients often rely on informal caregivers-relatives or friends-for assistance with functioning and support. Caregivers perform roles that may be particularly important during acute exacerbations in monitoring symptoms and seeking medical intervention. However, little is known about caregivers' roles and experiences as they support their patients during exacerbations.

Purpose: To explore the experiences, roles in care seeking, and needs of caregivers during COPD exacerbations.

Methods: Semi-structured interviews were conducted with 24 caregivers of Veterans with COPD who experienced a recent exacerbation. Interviews were recorded, transcribed, and analyzed using inductive content analysis.

Results: Five themes arose: (a) caregivers reported continuously monitoring changes in patients symptom severity to identify exacerbations; (b) caregivers described emotional reactions evoked by exacerbations and constant vigilance; (c) caregivers described disagreements with their patient in interpreting symptoms and determining the need for care seeking; (d) caregivers noted uncertainty regarding their roles and responsibilities in pursuing care and their approaches to promote care varied; and (e) expressed their need for additional information and support. Caregivers of patients with COPD often influence whether and when patients seek care during exacerbations. Discrepancies in symptom evaluations between patients and caregivers paired with the lack of information and support available to caregivers are related to delays in care seeking. Clinical practice should foster self-management support to patient-caregiver dyads to increase caregiver confidence and patient openness to their input during exacerbations.
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http://dx.doi.org/10.1093/abm/kaab045DOI Listing
June 2021

Psychotherapy and depressive symptom trajectories among VA patients: Comparing dose-effect and good-enough level models.

J Consult Clin Psychol 2021 May;89(5):379-392

Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Health Care System.

Psychotherapy for depression is effective for many veterans, but the relationship between number of treatment sessions and symptom outcomes is not well established. The Dose-Effect model predicts that greater psychotherapeutic dose (total sessions) yields greater symptom improvement with each additional session resulting in smaller session-to-session improvement. In contrast, the Good-Enough Level (GEL) model predicts that rate of symptom improvement varies by total psychotherapeutic dose with faster improvement associated with earlier termination. This study compared the dose-effect and GEL model among veterans receiving psychotherapy for depression within the Veterans Health Administration. The sample included 13,647 veterans with ≥2 sessions of psychotherapy for depression with associated Patient Health Questionnaire-9 (PHQ-9) scores in primary care ( = 7,502) and specialty mental health clinics ( = 6,145) between October 2014 and September 2018. Multilevel longitudinal modeling was used to compare the Dose-Effect and GEL models within each clinic type. The GEL model demonstrated greater fit for both clinic types relative to dose-effect models. In both treatment settings, veterans with fewer sessions improved faster than those with more sessions. In primary care clinics, veterans who received 4-8 total sessions achieved similar levels of symptom response. In specialty mental health clinics, increased psychotherapeutic dose was associated with greater treatment response up to 16 sessions. Veterans receiving 20 sessions demonstrated minimal treatment response. These findings support the GEL model and suggest a flexible approach to determining length of psychotherapy for depression may be useful for optimizing treatment response and allocation of clinical resources. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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http://dx.doi.org/10.1037/ccp0000645DOI Listing
May 2021

Long-term care service mix in the Veterans Health Administration after home care expansion.

Health Serv Res 2021 Jun 3. Epub 2021 Jun 3.

Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA.

Objective: To determine whether the Veterans Health Administration's (VHA) efforts to expand access to home- and community-based services (HCBS) after the 2001 Millennium Act significantly changed Veterans' utilization of institutional, paid home, and unpaid home care relative to a non-VHA user Medicare population that was not exposed to HCBS expansion efforts.

Data Sources: We used linkages between the Health and Retirement Study and VHA administrative data from 1998 until 2012.

Study Design: We conducted a retrospective-matched cohort study using coarsened exact matching to ensure balance on observable characteristics for VHA users (n = 943) and nonusers (n = 6106). We used a difference-in-differences approach with a person fixed-effects estimator.

Data Collection/extraction Methods: Individuals were eligible for inclusion in the analysis if they were age 65 or older and indicated that they were covered by Medicare insurance in 1998. Individuals were excluded if they were covered by Medicaid insurance at baseline. Individuals were considered exposed to VHA HCBS expansion efforts if they were enrolled in the VHA and used VHA services.

Principal Findings: Theory predicts that an increase in the public allocation of HCBS will decrease the utilization of its substitutes (e.g., institutional care and unpaid caregiving). We found that after the Millennium Act was passed, there were no observed differences between VHA users and nonusers in the probability of using institutional long-term care (0.7% points, 95% CI: -0.009, 0.022) or in receiving paid help with activities of daily living (0.06% points, 95% CI: -0.011, 0.0125). VHA users received more hours of unpaid care post-Millennium Act (1.48, 95% CI: -0.232, 3.187), though this effect was not significant once we introduced controls for mental health.

Conclusions: Our findings indicate that mandating access to HCBS services does not necessarily imply that access to these services will follow suit.
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http://dx.doi.org/10.1111/1475-6773.13687DOI Listing
June 2021

Improving Uptake of a National Web-Based Psychoeducational Workshop for Informal Caregivers of Veterans: Mixed Methods Implementation Evaluation.

J Med Internet Res 2021 01 7;23(1):e16495. Epub 2021 Jan 7.

Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, CA, United States.

Background: Although web-based psychoeducational programs may be an efficient, accessible, and scalable option for improving participant well-being, they seldom are sustained beyond trial publication. Implementation evaluations may help optimize program uptake, but few are performed. When the US Department of Veterans Affairs (VA) launched the web-based psychoeducational workshop Building Better Caregivers (BBC) for informal caregivers of veterans nationwide in 2013, the workshop did not enroll as many caregivers as anticipated.

Objective: This study aims to identify the strengths and weaknesses of initial implementation, strategies likely to improve workshop uptake, whether the VA adopted these strategies, and whether workshop enrollment changed.

Methods: We used mixed methods and the Promoting Action on Research Implementation in Health Services (PARIHS) implementation evaluation framework. In stage 1, we conducted semistructured interviews with caregivers, local staff, and regional and national VA leaders and surveys with caregivers and staff. We collected and analyzed survey and interview data concurrently and integrated the results to identify implementation strengths and weaknesses, and strategies likely to improve workshop uptake. In stage 2, we reinterviewed national leaders to determine whether the VA adopted recommended strategies and used national data to determine whether workshop enrollment changed over time.

Results: A total of 54 caregivers (n=32, 59%), staff (n=13, 24%), and regional (n=5, 9%) and national (n=4, 7%) leaders were interviewed. We received survey responses from 72% (23/32) of caregivers and 77% (10/13) of local staff. In stage 1, survey and interview results were consistent across multiple PARIHS constructs. Although participants from low-enrollment centers reported fewer implementation strengths and more weaknesses, qualitative themes were consistent across high- and low-enrollment centers, and across caregiver, staff, and leadership respondent groups. Identified strengths included belief in a positive workshop impact and the use of some successful outreach approaches. Implementation weaknesses included missed opportunities to improve outreach and to better support local staff. From these, we identified and recommended new and enhanced implementation strategies-increased investment in outreach and marketing capabilities; tailoring outreach strategies to multiple stakeholder groups; use of campaigns that are personal, repeated, and detailed, and have diverse delivery options; recurrent training and mentoring for new staff; and comprehensive data management and reporting capabilities. In stage 2, we determined that the VA had adopted several of these strategies in 2016. In the 3 years before and after adoption, cumulative BBC enrollment increased from 2139 (2013-2015) to 4030 (2016-2018) caregivers.

Conclusions: This study expands the limited implementation science literature on best practices to use when implementing web-based psychoeducational programs. We found that robust outreach and marketing strategies and support for local staff were critical to the implementation success of the BBC workshop. Other health systems may want to deploy these strategies when implementing their web-based programs.
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http://dx.doi.org/10.2196/16495DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7819783PMC
January 2021

Relationship between adult and family supporter health literacy levels and supporter roles in diabetes management.

Fam Syst Health 2020 Dec 28. Epub 2020 Dec 28.

VA Pittsburgh Healthcare System.

Introduction: Among adults with Type 2 diabetes, low health literacy (HL) is a risk factor for negative health outcomes. Support from family and friends can improve adults' self-management and health-related outcomes. We examined whether supporters provided unique help to adults with diabetes and low HL and whether HL was associated with adults' perception of supporter helpfulness.

Methods: We used cross-sectional baseline survey data from 239 adult patients with diabetes enrolled in a randomized controlled trial with a support person. Patients reported level of supporter involvement with self-management roles. HL among patients and supporters was assessed using a validated HL screening tool. Patient perception of supporter helpfulness was assessed with a single item. We used multivariable logistic regression to examine associations of patient and supporter HL levels with supporter roles and patients' perception of supporter helpfulness.

Results: Patients with low HL were more likely to have a supporter with low HL (39% vs. 26%, p = .04). Patients with low HL had higher odds of receiving supporter help with calling health care providers (adjusted odds ratio [AOR] = 2.09, 95% CI [1.00, 4.39]), remembering medical appointments (AOR = 2.24, 95% CI [1.07, 4.69]), and giving directions when blood sugars were low (AOR = 2.51, 95% CI [1.20, 5.37]). Neither patient nor supporter HL was significantly associated with patients' perception of supporter helpfulness.

Discussion: Adults with diabetes and low HL reported more supporter involvement with specific self-management tasks than patients with adequate HL. Providers could consider targeted involvement of supporters to assist patients with chronic diseases and low HL, although they should be aware that supporters may be challenged by low HL. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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http://dx.doi.org/10.1037/fsh0000503DOI Listing
December 2020

Autonomy support from informal health supporters: links with self-care activities, healthcare engagement, metabolic outcomes, and cardiac risk among Veterans with type 2 diabetes.

J Behav Med 2021 04 27;44(2):241-252. Epub 2020 Nov 27.

VA Center for Health Equity Research and Promotion, Pittsburgh, PA, USA.

This study examined the role of autonomy support from adults' informal health supporters (family or friends) in diabetes-specific health behaviors and health outcomes. Using baseline data from 239 Veterans with type 2 diabetes at risk of complications enrolled in behavioral trial, we examined associations between autonomy support from a support person and that support person's co-residence with the participant's diabetes self-care activities, patient activation, cardiometabolic measures, and predicted risk of a cardiac event. Autonomy support from supporters was associated with significantly increased adherence to healthy lifestyle behaviors (diet, p < .001 and exercise, p = .003); higher patient activation (p < .001); greater patient efficacy in interacting with healthcare providers, and lower 5-year (p = .044) and 10-year (p = .027) predicted cardiac risk. Autonomy support was not significantly associated with diabetes-specific behaviors (checking blood glucose, foot care, or medication taking); or hemoglobin A1c, systolic blood pressure, or non-HDL cholesterol. There was a significant interaction of autonomy support and supporter residence in one model such that lack of autonomy support was associated with lower patient activation only among individuals with in-home supporters. No other interactions were significant. Findings suggest that autonomy support from family and friends may play a role in patient self-management, patient activation, and lower cardiac risk.
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http://dx.doi.org/10.1007/s10865-020-00196-5DOI Listing
April 2021

Patient, caregiving partner, and clinician recommendations for improving heart failure care in the Veterans Health Administration.

Chronic Illn 2020 Oct 28:1742395320966366. Epub 2020 Oct 28.

Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, USA.

Objective: Heart Failure (HF) care requires substantial care coordination between patients, patients' informal caregivers, and clinicians, but few studies have examined recommendations from all three perspectives. The objective of this study was to understand and identify shared recommendations to improve HF self-care from the perspective of VA persons with HF, their caregiving partners, and clinicians.

Methods: Secondary data analysis from a study of semi-structured interviews with 16 couples (persons with HF and their caregiving partners) and 13 clinicians (physicians, nurses, other specialists) from a large Veterans Affairs (VA) hospital. Interviews were double-coded, and analyzed for themes around commonly used or recommended self-care strategies.

Results: Three themes emerged: (1) Couples and clinicians believe that improvements are still needed to existing HF education, especially the need to be tailored to learning style and culture, (2) Couples and clinicians believe that technology can facilitate better HF self-care, and (3) Couples and clinicians believe that caregiving partners are part of the self-care team, and should be involved in care management to support the person with HF.

Discussion: Recommendations from couples and clinicians address barriers to HF self-care and encourage patient-centered care.
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http://dx.doi.org/10.1177/1742395320966366DOI Listing
October 2020

Association of Veterans Affairs Primary Care Mental Health Integration With Care Access Among Men and Women Veterans.

JAMA Netw Open 2020 10 1;3(10):e2020955. Epub 2020 Oct 1.

Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California.

Importance: Women veterans increasingly seek care yet continue to face barriers in the Veterans Health Administration (VA), which predominantly cares for men. Evidence-based collaborative care models can improve patient access to treatment of depression, which is experienced at higher rates by women. While the VA has implemented these care models nationally, it is not known whether access improvements occur equitably across genders in primary care.

Objective: To examine whether the VA's national Primary Care-Mental Health Integration (PC-MHI) initiative (beginning 2007) expanded realized access to mental health care similarly for men and women.

Design, Setting, And Participants: This cohort study included 5 377 093 million primary care patients assigned to 396 VA clinics that provided integrated mental health services nationally between October 2013 and September 2016. Data analysis occurred between May 2017 and July 2020.

Exposures: Clinic PC-MHI penetration, calculated as the proportion of clinic patients who saw an integrated specialist per fiscal year.

Main Outcomes And Measures: Estimates of mean VA health care utilization (mental health, primary care, other specialty care, telephone, hospitalizations) and median total costs for men and women. Multilevel models adjusted for year, clinic, patient characteristics, and interactions between patient-defined gender and clinic PC-MHI penetration.

Results: This study examined 5 377 093 veterans (448 455 [8.3%] women; 3 744 140 [69.6%] White) with a mean (SD) baseline age 62.0 (16.6) years. Each percentage-point increase in the proportion of clinic patients who saw an integrated specialist was associated with 38% fewer mental health visits per year for women (incidence rate ratio [IRR], 0.62; 95% CI, 0.60-0.65), but 39% more visits for men (IRR, 1.39; 95% CI, 1.34-1.44; P < .001). Both men and women had more primary care visits (men: IRR, 1.40; 95% CI, 1.36-1.45; women: IRR, 1.22; 95% CI, 1.17-1.28; P < .001) and total costs (men: β [SE], 2.23 [0.10]; women: β [SE], 1.24 [0.15]; P = .06), but women had 74% fewer hospitalizations than men related to clinics with mental health integration (IRR, 0.26; 95% CI, 0.19-0.36 vs IRR, 1.02; 95% CI, 0.83-1.24; P < .001).

Conclusions And Relevance: While greater outpatient service use for men was observed in this study, PC-MHI was associated with a decrease in mental health specialty visits (and hospitalizations) for women veterans, potentially signifying a shift of services to primary care. With increasing patient choice for where veterans receive care, the VA must tailor medical care to the needs of rising numbers of women patients. Differences in health care utilization by gender highlight the importance of anticipating policy impacts on and tailoring services for patients in the numerical minority in the VA and other health systems.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.20955DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7576407PMC
October 2020

Diabetes Distress Among Dyads of Patients and Their Health Supporters: Links With Functional Support, Metabolic Outcomes, and Cardiac Risk.

Ann Behav Med 2020 Oct 12. Epub 2020 Oct 12.

VA Center for Health Equity Research and Promotion, Pittsburgh, PA.

Background: Patients with diabetes (PWD) often experience diabetes distress which is associated with worse self-management and glycemic control. In contrast, PWD who receive support from family and friends (supporters) have better diabetes outcomes.

Purpose: To examine the associations of PWD diabetes distress and supporters' distress about PWDs' diabetes with supporters' roles and PWD cardiometabolic outcomes.

Methods: We used baseline data from 239 adults with Type 2 diabetes and their supporters participating in a longitudinal trial. PWD and supporter diabetes distress (high vs. low) were determined using the Problem Areas in Diabetes Scale-5. Outcomes included PWD-reported help from supporters with self-care activities, supporter-reported strain, PWD metabolic outcomes (glycemic control [HbA1c], systolic blood pressure [SBP], and non-HDL cholesterol) and 5 and 10 year risk of cardiac event (calculated using the United Kingdom Prospective Diabetes Study algorithm).

Results: PWDs with high diabetes distress were more likely to report that their supporters helped with taking medications, coordinating medical care, and home glucose testing (p's < .05), but not more likely to report help with diet or exercise. High supporter distress was associated with greater supporter strain (p < .001). High supporter diabetes distress was associated with higher PWD HbA1c (p = .045), non-HDL cholesterol (p = .011), and 5 (p = .002) and 10 year (p = .001) cardiac risk.

Conclusions: Adults with high diabetes distress report more supporter help with medically focused self-management but not with diet and exercise. Supporter distress about PWD diabetes was consistently associated with worse outcomes. PWD diabetes distress had mixed associations with their diabetes outcomes.
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http://dx.doi.org/10.1093/abm/kaaa081DOI Listing
October 2020

Perceptions of time spent pursuing cancer care among patients, caregivers, and oncology professionals.

Support Care Cancer 2021 May 15;29(5):2493-2500. Epub 2020 Sep 15.

Stanford Cancer Institute, Stanford University, Stanford, CA, USA.

Purpose: Patients with cancer spend significant time receiving treatment and recovering from side effects. Little is known about how patients and their caregivers perceive time spent receiving cancer treatment and how this impacts health-related quality of life (HRQoL). Our study aims to characterize perceptions of time invested in receiving cancer therapy as experienced by patients, caregivers, and oncology professionals.

Methods: We conducted semi-structured interviews with patients undergoing treatment for advanced lung cancer and melanoma, their informal caregivers, and oncology professionals (physicians, nurses, social workers, and chaplains). Participants received and provided care at a tertiary cancer center. Interviews were audiorecorded and transcribed verbatim. Transcripts were analyzed qualitatively using predominantly inductive coding to identify themes relating to time perception and cancer care.

Results: We interviewed 29 participants (11 patients, 7 informal caregivers, and 11 oncology professionals) and found they consistently differentiated between time remaining in life ("existential time") and time required to manage cancer treatment and symptoms ("chronological time"). Patients and caregivers reported distress around the mechanics of oncologic care that interrupted their daily lives (hobbies, activities). Participants described the impact of time invested in cancer care on dimensions of quality of life, ranging from minimal to substantial negative impact.

Conclusions: We found that the time spent undergoing cancer treatment affects well-being and often prevents patients and caregivers from participating in meaningful activities. The investment of personal time undergoing cancer therapy for patients with advanced solid tumors merits further study and can enhance communication between patients, caregivers, and their oncologists.
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http://dx.doi.org/10.1007/s00520-020-05763-9DOI Listing
May 2021

Caring for Caregivers During COVID-19.

J Am Geriatr Soc 2020 10 11;68(10):2197-2201. Epub 2020 Aug 11.

South Texas Veterans Health Care System, Research, San Antonio, Texas, USA.

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http://dx.doi.org/10.1111/jgs.16726DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7361597PMC
October 2020

Perspectives of Veterans Affairs mental health providers on working with older adults with dementia and their caregivers.

Gerontol Geriatr Educ 2021 Jan-Mar;42(1):114-125. Epub 2020 May 18.

W.S. Middleton Memorial Veterans Hospital, Madison, Wisconsin, USA.

Continuing education directed at building providers' skills and knowledge in geriatrics represents a practical approach to addressing the geriatric mental health (MH) care workforce shortage. To inform the development of professional training curricula, we surveyed MH providers (N = 65) at a Veterans Affairs medical center on working with older persons with dementia (PwD) and informal caregivers. Providers rated service provision to PwD and caregivers as highly important but endorsed modest self-efficacy. Half of respondents were minimally confident in managing risk of harm to self or others in a PwD. Respondents believed PwD can benefit from MH treatments, yet identified several barriers to providing care, including inadequate time and staffing resources. Interest in geriatric training topics was high. Findings demonstrate that MH providers at this site value care provision to PwD and caregivers, and desire additional training to serve this population. System-level barriers to MH care for PwD should also be identified and addressed.
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http://dx.doi.org/10.1080/02701960.2020.1764356DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7671942PMC
May 2020

Perspectives of Veterans Affairs mental health providers on working with older adults with dementia and their caregivers.

Gerontol Geriatr Educ 2021 Jan-Mar;42(1):114-125. Epub 2020 May 18.

W.S. Middleton Memorial Veterans Hospital, Madison, Wisconsin, USA.

Continuing education directed at building providers' skills and knowledge in geriatrics represents a practical approach to addressing the geriatric mental health (MH) care workforce shortage. To inform the development of professional training curricula, we surveyed MH providers (N = 65) at a Veterans Affairs medical center on working with older persons with dementia (PwD) and informal caregivers. Providers rated service provision to PwD and caregivers as highly important but endorsed modest self-efficacy. Half of respondents were minimally confident in managing risk of harm to self or others in a PwD. Respondents believed PwD can benefit from MH treatments, yet identified several barriers to providing care, including inadequate time and staffing resources. Interest in geriatric training topics was high. Findings demonstrate that MH providers at this site value care provision to PwD and caregivers, and desire additional training to serve this population. System-level barriers to MH care for PwD should also be identified and addressed.
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http://dx.doi.org/10.1080/02701960.2020.1764356DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7671942PMC
May 2020

The Dyadic Experience of Managing Heart Failure: A Qualitative Investigation.

J Cardiovasc Nurs 2020 Jan/Feb;35(1):12-18

Background: Self-management of heart failure (HF) is often a joint venture between patients and their friends and family ("framily"). However, this joint experience is often overlooked in clinical care.

Objectives: The aim of this study was to understand the cognitive, emotional, and relational elements affecting the experience of patient-framily member dyads managing HF.

Methods: Participants were patients with HF receiving care at a university hospital and their framily. Dyads participated in 30- to 45-minute semistructured interviews before their clinic visit. Transcribed interviews were analyzed using thematic analyses. Interviews were coded independently and checked for interrater agreement before the final coded data set was developed. Participants were recruited until thematic saturation was attained.

Results: A total of 16 patient-framily member dyads and 1 triad (n = 35) participated in the study; 47.1% of patients and 77.8% of framily members were female. Patients were 66 years old (SD, 14 years) and framily members were 59 years old (SD, 12.3 years). Three aspects of the dyadic experience emerged in the themes: (1) health beliefs of dyads were characterized by acceptance and optimism, but also pessimism; (2) negative emotions influenced the dyadic experience; (3) the closeness of their interpersonal relationships influenced their contributions to managing HF.

Conclusions: Our study suggests that greater attention to the experience and interpersonal relationships of dyads has the potential for improving HF self-management and facilitating patient-centered care.
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http://dx.doi.org/10.1097/JCN.0000000000000605DOI Listing
June 2021

Mortality Among Veterans with Major Mental Illnesses Seen in Primary Care: Results of a National Study of Veteran Deaths.

J Gen Intern Med 2020 01 30;35(1):112-118. Epub 2019 Oct 30.

Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, USA.

Background: Premature mortality observed among the mentally ill is largely attributable to chronic illnesses. Veterans seen within Veterans Affairs (VA) have a higher prevalence of mental illness than the general population but there is limited investigation into the common causes of death of Veterans with mental illnesses.

Objective: To characterize the life expectancy of mentally ill Veterans seen in VA primary care, and to determine the most death rates of combinations of mental illnesses.

Design: Retrospective cohort study of decedents.

Setting/participants: Veterans seen in VA primary care clinics between 2000 and 2011 were included. Records from the VA Corporate Data Warehouse (CDW) were merged with death information from the National Death Index.

Main Measures: Mental illnesses were determined using ICD9 codes. Direct standardization methods were used to calculate age-adjusted gender and cause-specific death rates per 1000 deaths for patients with and without depression, anxiety, post-traumatic stress disorder (PTSD), substance use disorder (SUD), serious mental illness (SMI), and combinations of those diagnoses.

Key Results: Of the 1,763,982 death records for Veterans with 1 + primary care visit, 556,489 had at least one mental illness. Heart disease and cancer were the two leading causes of death among Veterans with or without a mental illness, accounting for approximately 1 in 4 deaths. Those with SUD (n = 204,950) had the lowest mean age at time of death (64 ± 12 years). Among men, the death rates were as follows: SUD (55.9/1000); anxiety (49.1/1000); depression (45.1/1000); SMI (40.3/1000); and PTSD (26.2/1000). Among women, death rates were as follows: SUD (55.8/1000); anxiety (36.7/1000); depression (45.1/1000); SMI (32.6/1000); and PTSD (23.1/1000 deaths). Compared to men (10.8/1000) and women (8.7/1000) without a mental illness, these rates were multiple-fold higher in men and in women with a mental illness. A greater number of mental illness diagnoses was associated with higher death rates among men and women (p < 0.0001).

Conclusions: Veterans with mental illnesses, particularly those with SUD, and those with multiple diagnoses, had shorter life expectancy than those without a mental illness. Future studies should examine both patient and systemic sources of disparities in providing chronic illness care to Veterans with a mental illness.
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http://dx.doi.org/10.1007/s11606-019-05307-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6957595PMC
January 2020

Veterans Health Administration Investments In Primary Care And Mental Health Integration Improved Care Access.

Health Aff (Millwood) 2019 08;38(8):1281-1288

Ranak B. Trivedi is a core investigator at the Center for Innovation to Implementation, VA Palo Alto Healthcare System, and an assistant professor of psychiatry in the Department of Public Mental Health and Population Sciences, Stanford University, in Menlo Park, California.

Aiming to increase care access, the national Primary Care-Mental Health Integration (PC-MHI) initiative of the Veterans Health Administration (VHA) embedded specialists, care managers, or both in primary care clinics to collaboratively care for veterans with psychiatric illness. The initiative's effects on health care use and cost patterns were examined among 5.4 million primary care patients in 396 VHA clinics in 2013-16. The median rate of patients who saw a PC-MHI provider was 6.3 percent. Each percentage-point increase in the proportion of clinic patients seen by these providers was associated with 11 percent more mental health and 40 percent more primary care visits but also with 9 percent higher average total costs per patient per year. At the mean, 2.5 integrated care visits substituted for each specialty-based mental health visit that did not occur. PC-MHI was associated with improved access to outpatient care, albeit at increased total cost to the VHA. Successful implementation of integrated care necessitates significant investment and multidisciplinary partnership within health systems.
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http://dx.doi.org/10.1377/hlthaff.2019.00270DOI Listing
August 2019

Comparing the Barriers and Facilitators of Heart Failure Management as Perceived by Patients, Caregivers, and Clinical Providers.

J Cardiovasc Nurs 2019 Sep/Oct;34(5):399-409

Ranak B. Trivedi, PhD Core Investigator, Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto; and Assistant Professor, Division of Public Mental Health and Population Sciences, Department of Psychiatry and Behavioral Sciences, Stanford University, California. Cindie Slightam, MPH Research Health Science Specialist, Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California. Andrea Nevedal, PhD Core Investigator, Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California. Timothy C. Guetterman, PhD Assistant Professor, Department of Family Medicine, University of Michigan, Ann Arbor. Vincent S. Fan, MD, MPH Core Investigator, Seattle-Denver Center of Innovation, VA Puget Sound Health Care System, Seattle, Washington; and Associate Professor, Department of Medicine, University of Washington, Seattle. Karin M. Nelson, MD, MSHS Core Investigator, Seattle-Denver Center of Innovation, VA Puget Sound Health Care System, Seattle, Washington; and Professor, Department of Medicine, University of Washington, Seattle. Ann-Marie Rosland, MD Core Investigator, Center for Health Equity, VA Pittsburgh Health Care System; and Associate Professor, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pennsylvania. Paul A. Heidenreich, MD Core Investigator, Center for Innovation to Implementation, VA Palo Alto Health Care System; and Professor, Division of Cardiology, Stanford University School of Medicine, California. Christine Timko, PhD Research Career Scientist, Center for Innovation to Implementation, VA Palo Alto Health Care System, California. Steven M. Asch, MD, MPH Director, Center for Innovation to Implementation, VA Palo Alto Health Care System; and Professor, Division of General Internal Medicine, Stanford University School of Medicine, California. John D. Piette, PhD Senior Research Career Scientist, Center for Practice Management and Outcomes Research, VA Ann Arbor Health Care System, Michigan; and Director, Center for Managing Chronic Disease, School of Public Health, University of Michigan, Ann Arbor.

Background: Heart failure (HF) management requires the participation of patients, their significant others, and clinical providers. Each group may face barriers to HF management that may be unique or may overlap.

Objective: The aim of this study was to compare the barriers and facilitators of HF management as perceived by patients, significant others, and clinical providers.

Methods: Participants were recruited from a Veterans Health Administration facility. Eligible patients had a diagnosis of HF (ICD9 code 428.XX), 1 or more HF-related visit in the previous year, and a significant other who was their primary caregiver. Significant others were adults with no history of cognitive impairments caring for patients with HF. Providers were eligible if they cared for patients with HF. All participants completed semistructured interviews designed to elicit barriers to managing HF and strategies that they used to overcome these barriers. Interviews were transcribed and analyzed using latent thematic analysis, and recruitment continued until thematic saturation was attained.

Results: A total of 17 couples and 12 providers were recruited. All 3 groups identified poor communication as a key barrier to HF management, including communication between patients and their significant other, between couples and providers, and providers with each other. Significant others noted that the lack of direct communication with clinical providers hindered their efforts to care for the patient. All 3 groups emphasized the importance of family members in optimizing adherence to HF self-management recommendations.

Conclusions: Providers, patients, and significant others all play important and distinct roles in the management of HF. Tools to enhance communication and collaboration for all 3 and supporting the needs of significant others are missing components of current HF care.
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http://dx.doi.org/10.1097/JCN.0000000000000591DOI Listing
July 2020

Clinical Care Quality Among Veterans Health Administration Patients With Mental Illness Following Medical Home Implementation.

Psychiatr Serv 2019 09 16;70(9):816-823. Epub 2019 Jul 16.

Centers of Excellence in Substance Addiction Treatment and Education, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, and Corporal Michael J. Crescenz VA Medical Center, Philadelphia (Browne); Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research and Development, VA Puget Sound Health Care System (Hoerster, Fortney, Nelson); Department of Psychiatry and Behavioral Sciences (Browne, Hoerster, Fortney) and School of Medicine (Nelson, Fihn), University of Washington, Seattle; Office of Clinical Systems Development and Evaluation, Veterans Health Administration (VHA), Washington, D.C. (Piegari); VA Ann Arbor Health Care System, Ann Arbor, Michigan (Post); VHA Office of Primary Care, Primary Care Analytics Team (PCAT), Seattle (Mori); Center for Innovation to Implementation, Palo Alto Health Care System, Palo Alto, California, and Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California (Trivedi).

Objective: This study sought to compare quality of care following medical home implementation among Veterans Health Administration (VHA) primary care patients with and without mental illness.

Methods: VHA primary care patients seen between April 2010 and March 2013 whose medical records were reviewed by the VHA External Peer Review Program were identified. The proportion of patients meeting quality indicators in each mental illness group (depression, posttraumatic stress disorder, anxiety disorder, substance use disorder, serious mental illness, and any mental illness) was compared with the proportion of patients without mental illness. Sample sizes ranged from 210,864 to 236,421. Differences of 5.0% or greater were deemed clinically important, and higher proportions indicated higher quality of care across 33 clinical indicators.

Results: The proportion of veterans meeting clinical quality indicators ranged from 64.7% to 99.6%. Differences of ≥5.0% between veterans with and without mental illness were detected in six of 33 indicators. A greater proportion of veterans with mental illness received influenza immunizations (age 50-64) and had documented left ventricular functioning (among veterans with chronic heart failure) compared with veterans without mental illness. A lower proportion of veterans with substance use disorders or severe mental illness received colorectal cancer screening or met indicators related to recommended medications if diagnosed as having diabetes or ischemic heart disease.

Conclusions: Contrary to earlier reports of lower-quality care, patients with and without mental illness had similar preventive and chronic disease management care quality following medical home implementation.
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http://dx.doi.org/10.1176/appi.ps.201800474DOI Listing
September 2019

Understanding communal coping among patients and informal caregivers with heart failure: A mixed methods secondary analysis of patient-caregiver dyads.

Heart Lung 2019 Nov - Dec;48(6):486-495. Epub 2019 Jun 3.

Veteran Affairs Palo Alto Health Care System, Menlo Park Division, 795 Willow Rd, Menlo Park, CA 94025, United States; Stanford University, Department of Psychiatry and Behavioral Sciences, Stanford, CA, United States.

Background: Dyads that view illnesses as shared stressors ("shared appraisal"), and collaboratively respond to it, have better outcomes. This process, known as communal coping, has received little attention in heart failure (HF).

Objectives: To examine communal coping among patient-caregiver dyads managing HF.

Methods: We conducted semi-structured interviews with 34 dyads. Shared appraisal was measured using we-ratio, as calculated with Linguistic Inquiry Word Count. We-ratio was divided into "high" and "low" for patients and caregivers, and concordance was examined. Thematic analyses were used to explore collaboration.

Results: Caregivers had higher we-ratios than patients (p=.005); 29.6% and 33.3% dyads were concordant on high and low "we-ratio," respectively. In thematic analyses, we found that 1) dyads collaborated around diet, appointments, and medications, but less around physical activity; 2) dyads collaborated across all illnesses, not just HF; and 3) dyads concordant on high we-ratio reported stronger collaborations.

Conclusions: Communal coping varied by shared appraisal and collaboration. Understanding this variability may help develop tailored self-management interventions.
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http://dx.doi.org/10.1016/j.hrtlng.2019.05.008DOI Listing
March 2020

Neurologist Strategies for Optimizing the Parkinson's Disease Clinical Encounter.

J Geriatr Psychiatry Neurol 2019 09 2;32(5):246-256. Epub 2019 May 2.

1 Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, USA.

Objective: For patients with Parkinson's disease (PD), effective communication during neurology encounters is critical to ensuring the treatment plan maximizes quality of life. However, few research studies have engaged neurologists as key experts in identifying opportunities to optimize the clinical encounter. In this study, 16 neurologists from 4 clinic sites participated in hour-long semistructured interviews targeting opportunities to better address patients' quality of life needs.

Main Findings: Neurologists identified opportunities to meet needs across 4 domains: (1) PD patient education materials and self-management tools to facilitate clinical communication; (2) techniques for improving clinical communication, including strategies for eliciting nonmotor symptoms and contextualizing symptoms to better meet patient quality of life needs; (3) addressing system-level barriers, including time constraints and the lack of an identified specialist referral network; and (4) training in how to lead difficult conversations.

Principal Conclusions: Neurologists identified specific barriers, and proposed solutions, to improving care delivery for patients with PD. Integrating practice tools to address quality of life needs, training neurologists in communication around end-of-life care, and strengthening referral networks for rehabilitation and psychosocial support hold promise for improving quality of life for patients with PD.
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http://dx.doi.org/10.1177/0891988719845509DOI Listing
September 2019

Can We Improve Patient Adherence by Harnessing Social Forces?

J Gen Intern Med 2019 06;34(6):785-786

Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, CA, USA.

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http://dx.doi.org/10.1007/s11606-019-04856-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6544675PMC
June 2019

Relationship and communication characteristics associated with agreement between heart failure patients and their Carepartners on patient depressive symptoms.

Aging Ment Health 2019 09 20;23(9):1122-1129. Epub 2018 Dec 20.

e Center for Innovation to Implementation, VA Palo Alto Health Care System , Palo Alto , CA , USA.

Informal caregivers who recognize patients' depressive symptoms can better support self-care and encourage patients to seek treatment. We examined patient-caregiver agreement among patients with heart failure (HF). Our objectives were to (1) identify distinct groups of HF patients and their out-of-home informal caregivers (CarePartners) based on their relationship and communication characteristics, and (2) compare how these groups agree on the patients' depressive symptoms. We used baseline data from a comparative effectiveness trial of a self-care support program for veterans with HF treated in outpatient clinics from 2009-2012. We used a cross-sectional design and latent class analysis (LCA) approach to identify distinct groups of patient-CarePartner dyads (n = 201) based on relationship and communication characteristics then evaluated agreement on patients' depressive symptoms within these groups. The LCA analysis identified four groups: (n = 102 dyads, 51%), (n = 33 dyads, 16%), (n = 35 dyads, 17%), and (n = 31 dyads, 15%). Dyadic agreement on the patients' depressive symptoms was highest in the (Kappa (κ) = 0.44, r = 0.39) and groups (κ = 0.19, r = 0.32), and relatively poor in the (κ = -0.20, r = 0.17) and (κ =-0.01, r = 0.004) groups. Patients in (61%) and groups (74%) more frequently had depression based on self-report than patients in (46%) and (34%) groups. Caregiver relationships in HF tend to be either , , , or Patients' depressive symptoms may negatively affect how they communicate with their caregivers. At the same time, improved patient-caregiver communication could enhance dyadic consensus about the patient's depressive symptoms.
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http://dx.doi.org/10.1080/13607863.2018.1481923DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6586543PMC
September 2019

Comparing Preventable Hospitalizations Among Veterans With and Without Mental Illnesses Before and After Implementation of PACT.

Psychiatr Serv 2018 12 10;69(12):1252-1258. Epub 2018 Oct 10.

Dr. Trivedi is with the Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California. She is also with the Center for Innovation to Implementation, Department of Veterans Affairs (VA) Palo Alto Health Care System, Palo Alto, California. Mr. Sylling, Dr. Wong, Ms. Mori, and Dr. Nelson are with the Seattle-Denver Center of Innovation in Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle. Dr. Wong and Dr. Nelson are also with the University of Washington, Seattle, where Dr. Wong is with the Department of Health Services and Dr. Nelson, along with Dr. Fihn, is with the Department of General Internal Medicine. Dr. Post is with the Center for Clinical Management Research, VA Ann Arbor Health Care System and the Department of Internal Medicine, University of Michigan, Ann Arbor.

Objectives: The authors examined whether the rate of preventable hospitalizations among veterans with mental illness changed after implementation of the Department of Veterans Affairs (VA) primary care medical home-Patient Aligned Care Teams (PACT).

Methods: A 12-year retrospective cohort analysis was conducted of data from 9,206,017 veterans seen in 942 VA primary care clinics between October 2003 and March 2015. Preventable hospitalizations were those related to ambulatory care-sensitive conditions (ACSCs), identified with ICD-9 codes. Changes in rates of ACSC-related hospitalizations were compared between patients with and without mental illness in two age groups (<65, ≥65). Patients with mental illness diagnoses were grouped as follows: depression, posttraumatic stress disorder, anxiety, substance use disorder, and serious mental illness. Interrupted time-series analysis was used to model long-term trends and detect deviations after PACT implementation.

Results: There was an overall increase in mental illness diagnoses across both age groups. Among older veterans (≥65) with any mental illness, the rate (per 1,000 patients) of ACSC-related hospitalizations was five fewer in the post-PACT period, compared with the pre-PACT period. Among younger veterans (<65), there was a slight increase in ACSC-related hospitalizations in years 3-5 post-PACT if they had any mental illness (.6 per 1,000 patients), depression (.3), anxiety (1.4), or a substance use disorder (.6).

Conclusions: In this retrospective, observational study examining large systemwide changes in clinical practice, mental illness was more likely to be diagnosed after PACT implementation, compared with before, and results suggested a benefit of PACT implementation among older veterans in terms of a reduction in ACSC-related hospitalizations.
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http://dx.doi.org/10.1176/appi.ps.201700316DOI Listing
December 2018

"It's a disease of families": Neurologists' insights on how to improve communication and quality of life for families of Parkinson's disease patients.

Chronic Illn 2020 09 12;16(3):201-211. Epub 2018 Sep 12.

Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, USA.

Objectives: Parkinson's disease presents an evolving challenge for patients and families due to an unpredictable disease trajectory and symptoms that complicate social interactions. In this study, we explore neurologists' perspectives on the challenges Parkinson's disease presents for families and the strategies they use to improve communication and quality of life.

Methods: We conducted hour-long semi-structured interviews with 16 neurologists at 4 care delivery institutions in the San Francisco Bay Area, focusing on techniques neurologists use to support families through the Parkinson's disease journey.

Results: Neurologists identified strategies for addressing caregiver-patient disagreements around symptom accuracy and negotiating driving safety. Family education is needed to contextualize patient symptoms and to identify psychosocial support resources. Unmet caregiver needs remain, particularly in the form of psychosocial support, respite care and support for unequal gender dynamics in the Parkinson's disease caregiving experience.

Discussion: Family members of Parkinson's disease patients face unique caregiving and interpersonal challenges due to the nature of the disease. Targeted education and structural support are needed to alleviate current burdens and allow for improved patient- and family-centered care.
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http://dx.doi.org/10.1177/1742395318799852DOI Listing
September 2020

Engaging family supporters of adult patients with diabetes to improve clinical and patient-centered outcomes: study protocol for a randomized controlled trial.

Trials 2018 Jul 24;19(1):394. Epub 2018 Jul 24.

Veterans Affairs Center for Clinical Management Research, VA Ann Arbor Center for Clinical Management Research, 2215 Fuller Road, Ann Arbor, MI, 48105, USA.

Background: Most adults with diabetes who are at high risk for complications have family or friends who are involved in their medical and self-care ("family supporters"). These family supporters are an important resource who could be leveraged to improve patients' engagement in their care and patient health outcomes. However, healthcare teams lack structured and feasible approaches to effectively engage family supporters in patient self-management support. This trial tests a strategy to strengthen the capacity of family supporters to help adults with high-risk diabetes engage in healthcare, successfully enact care plans, and lower risk of diabetes complications.

Methods/design: We will conduct a randomized trial evaluating the CO-IMPACT (Caring Others Increasing EnageMent in Patient Aligned Care Teams) intervention. Two hunded forty adults with diabetes who are at high risk for diabetes complications due to poor glycemic control or high blood pressure will be randomized, along with a family supporter (living either with the patient or remotely), to CO-IMPACT or enhanced usual primary care for 12 months. CO-IMPACT provides patient-supporter dyads: it provides one coaching session addressing supporter techniques for helping patients with behavior change motivation, action planning, and proactive communication with healthcare providers; biweekly automated phone calls to prompt dyad action on new patient health concerns; phone calls to prompt preparation for patients' primary care visits; and primary care visit summaries sent to both patient and supporter. Primary outcomes are changes in patient activation, as measured by the Patient Activation Measure-13, and change in 5-year cardiac event risk, as measured by the United Kingdom Prospective Diabetes Study cardiac risk score for people with diabetes. Secondary outcomes include patients' diabetes self-management behaviors, diabetes distress, and glycemic and blood pressure control. Measures among supporters will include use of effective support techniques, burden, and distress about patient's diabetes care.

Discussion: If effective in improving patient activation and diabetes management, CO-IMPACT will provide healthcare teams with evidence-based tools and techniques to engage patients' available family or friends in supporting patient self-management, even if they live remotely. The core skills addressed by CO-IMPACT can be used by patients and their supporters over time to respond to changing patient health needs and priorities.

Trial Registration: ClinicalTrials.gov, NCT02328326 . Registered on 31 December 2014.
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http://dx.doi.org/10.1186/s13063-018-2785-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6057090PMC
July 2018

Emotional Impact of Illness and Care on Patients with Advanced Kidney Disease.

Clin J Am Soc Nephrol 2018 07;13(7):1022-1029

Anthropology, University of Washington, Seattle, Washington.

Background And Objectives: The highly specialized and technologically focused approach to care inherent to many health systems can adversely affect patients' emotional experiences of illness, while also obscuring these effects from the clinician's view. We describe what we learned from patients with advanced kidney disease about the emotional impact of illness and care.

Design, Setting, Participants, & Measurements: As part of an ongoing study on advance care planning, we conducted semistructured interviews at the VA Puget Sound Healthcare System in Seattle, Washington, with 27 patients with advanced kidney disease between April of 2014 and May of 2016. Of these, ten (37%) were receiving center hemodialysis, five (19%) were receiving peritoneal dialysis, and 12 (44%) had an eGFR≤20 ml/min per 1.73 m and had not started dialysis. Interviews were audiotaped, transcribed, and analyzed inductively using grounded theory methods.

Results: We here describe three emergent themes related to patients' emotional experiences of care and illness: () emotional impact of interactions with individual providers: when providers seemed to lack insight into the patient's experience of illness and treatment, this could engender a sense of mistrust, abandonment, isolation, and/or alienation; () emotional impact of encounters with the health care system: just as they could be affected emotionally by interactions with individual providers, patients could also be affected by how care was organized, which could similarly lead to feelings of mistrust, abandonment, isolation, and/or alienation; and () emotional impact of meaning-making: patients struggled to make sense of their illness experience, worked to apportion blame, and were often quick to blame themselves and to assume that their illness could have been prevented.

Conclusions: Interactions with individual providers and with the wider health system coupled with patients' own struggles to make meaning of their illness can take a large emotional toll. A deeper appreciation of patients' emotional experiences may offer important opportunities to improve care.
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http://dx.doi.org/10.2215/CJN.14261217DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6032592PMC
July 2018

Disability Rating, Age at Death, and Cause of Death in U.S. Veterans with Service-Connected Conditions.

Mil Med 2018 11;183(11-12):e371-e376

Department of Veterans Affairs Puget Sound Health Care System, 1660 South Columbian Way Seattle, WA.

Introduction: The association between disability and cause of death in Veterans with service-connected disabilities has not been studied. The objective of this study was to compare age at death, military service and disability characteristics, including disability rating, and cause of death by year of birth. We also examined cause of death for specific service-connected conditions.

Materials And Methods: This study used information from the VETSNET file, which is a snapshot of selected items from the Veterans Benefits Administration corporate database. We also used the National Death Index (NDI) for Veterans which is part of the VA Suicide Data Repository. In VETSNET, there were 758,324 Veterans who had a service-connected condition and died between the years 2004 and 2014. Using the scrambled social security number to link the two files resulted in 605,493 (80%) deceased Veterans. Age at death, sex, and underlying cause of death were obtained from the NDI for Veterans and military service characteristics and types of disability were acquired from VETSNET. We constructed age categories corresponding to period of service; birth years 1938 and earlier corresponded to Korea and World War II ("oldest"), birth years 1939-1957 to the Vietnam era ("middle"), and birth years 1958 and later to post Vietnam, Gulf War, and the more recent conflicts in Iraq and Afghanistan ("youngest").

Results: Sixty-two percent were in the oldest age category, 34% in the middle group, and 4% in the youngest one. The overall age at death was 75 ± 13 yr. Only 1.6% of decedents were women; among women 25% were in the youngest age group, while among men only 4% were in the youngest group. Most decedents were enlisted personnel, and 60% served in the U.S. Army. Nearly 61% had a disability rating of >50% and for the middle age group 54% had a disability rating of 100%. The most common service-connected conditions were tinnitus, hearing loss, and post-traumatic stress disorder (PTSD). In the oldest group, nearly half of deaths were due to cancer or cardiovascular conditions and <2% were due to external causes. In the youngest group, cardiovascular disease and cancer accounted for about 1/3 of deaths, whereas external causes or deaths due to accidents, suicide, or assault accounted for nearly 33% of deaths. For Veterans with service-connected PTSD or major depression; 6.5% of deaths were due to external causes whereas for Veterans without these conditions, only 3.1% were due to external causes.

Conclusion: The finding of premature death due to external causes in the youngest age group as well as the finding of higher proportions of external causes in those with PTSD or major depression should be of great concern to those who care for Veterans.
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http://dx.doi.org/10.1093/milmed/usy040DOI Listing
November 2018

Associations between having an informal caregiver, social support, and self-care among low-income adults with poorly controlled diabetes.

Chronic Illn 2017 12 20;13(4):239-250. Epub 2017 Feb 20.

1 Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research & Development, VA Puget Sound Health Care System, Seattle, WA, USA.

Objective To determine whether the presence of an informal caregiver and the patient's level of social support are associated with better diabetes self-care among adults with poorly controlled diabetes. Methods Cross-sectional study using baseline data from 253 adults of age 30-70 with poorly controlled diabetes. Participants who reported receiving assistance with their diabetes from a friend or family member in the past month were classified as having a caregiver. We used multivariate linear and logistic regression models to evaluate the associations between having a caregiver and level of social support with five self-reported diabetes self-care behaviors: diet, foot checks, blood glucose monitoring, medications, and physical activity. Results Compared to participants with no informal caregiver, those with an informal caregiver were significantly more likely to report moderate or high medication adherence (OR = 1.93, 95% CI: 1.07-3.49, p = 0.028). When we included social support in the model, having a caregiver was no longer significantly associated with medication adherence (OR = 1.50, 95% CI: 0.80-2.82), but social support score was (OR = 1.22, 95% CI: 1.03-1.45, p = 0.023). Discussion Among low-income adults with poorly controlled diabetes, having both an informal caregiver and high social support for diabetes may have a beneficial effect on medication adherence, a key self-care target to improve diabetes control.
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http://dx.doi.org/10.1177/1742395317690032DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6993051PMC
December 2017
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