Publications by authors named "Yuchiao Chang"

360 Publications

A Web-Based Intervention to Increase Smokers' Intentions to Participate in a Cessation Study Offered at the Point of Lung Screening: Factorial Randomized Trial.

JMIR Form Res 2021 Jun 30;5(6):e28952. Epub 2021 Jun 30.

Mongan Institute Health Policy Research Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States.

Background: Screen ASSIST is a cessation trial offered to current smokers at the point of lung cancer screening. Because of the unique position of promoting a prevention behavior (smoking cessation) within the context of a detection behavior (lung cancer screening), this study employed prospect theory to design and formatively evaluate a targeted recruitment video prior to trial launch.

Objective: The aim of this study was to identify which message frames were most effective at promoting intent to participate in a smoking cessation study.

Methods: Participants were recruited from a proprietary opt-in online panel company and randomized to a 2 (benefits of quitting vs risks of continuing to smoke at the time of lung screening; BvR) × 2 (gains of participating vs losses of not participating in a cessation study; GvL) message design experiment (N=314). The primary outcome was self-assessed intent to participate in a smoking cessation study. Message effectiveness and lung cancer risk perception measures were also collected. Analysis of variance examined the main effect of the 2 message factors and a least absolute shrinkage and selection operator (LASSO) approach identified predictors of intent to participate in a multivariable model. A mediation analysis was conducted to determine the direct and indirect effects of message factors on intent to participate in a cessation study.

Results: A total of 296 participants completed the intervention. There were no significant differences in intent to participate in a smoking cessation study between message frames (P=.12 and P=.61). In the multivariable model, quit importance (P<.001), perceived message relevance (P<.001), and affective risk response (ie, worry about developing lung cancer; P<.001) were significant predictors of intent to participate. The benefits of quitting frame significantly increased affective risk response (Mean 2.60 vs Mean 2.40; P=.03), which mediated the relationship between message frame and intent to participate (b=0.24; 95% CI 0.01-0.47; P=.03).

Conclusions: This study provides theoretical and practical guidance on how to design and evaluate proactive recruitment messages for a cessation trial. Based on our findings, we conclude that heavy smokers are more responsive to recruitment messages that frame the benefits of quitting as it increased affective risk response, which predicted greater intention to participate in a smoking cessation study.
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http://dx.doi.org/10.2196/28952DOI Listing
June 2021

Who Benefits Most? A Multisite Study of Coaching and Resident Well-being.

J Gen Intern Med 2021 Jun 7. Epub 2021 Jun 7.

Mongan Institute Health Policy Center, Massachusetts General Hospital, Boston, MA, USA.

Background: Coaching has been shown to improve resident well-being; however, not all benefit equally.

Objective: Assess predictors of changes in resident physician well-being and burnout in a multisite implementation of a Professional Development Coaching Program.

Design: Pre- and post-implementation surveys administered to participant cohorts at implementation sites in their intern year. Effect size was calculated comparing pre- and post-intervention paired data.

Participants: In total, 272 residents in their intern year at five internal medicine residency programs (Boston Medical Center, University Hospitals Cleveland Medical Center, Duke University, Emory University, Massachusetts General Hospital). Analyses included 129 residents with paired data.

Interventions: Interns were paired with a faculty coach trained in positive psychology and coaching skills and asked to meet quarterly with coaches.

Main Measures: Primary outcomes included Maslach Burnout Inventory depersonalization (DP) and emotional exhaustion (EE) subscales, and the PERMA well-being scale. Key predictors included site, demographics, intolerance of uncertainty, hardiness-resilience, gratitude, and coping. Program moderators included were reflection, goal setting, and feedback.

Key Results: Well-being (PERMA) changed from baseline to follow-up in all participants; females showed a decline and males an increase (-1.41 vs. .83, p = 0.04). Self-reflection was associated with positive change in PERMA (mean positive change 1.93, p = 0.009). Burnout (EE) declined in non-Hispanic white residents vs. Black/Asian/Hispanic/other residents (-1.86, p = 0.021). Burnout improved with increased goal setting.

Conclusion: Coaching programs should consider tailored approaches to support residents whose well-being is impacted by gender and/or race, and who have higher intolerance of uncertainty and lower resilience at baseline. Coaching skills of goal setting and reflection may positively affect interns and teach coping skills.
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http://dx.doi.org/10.1007/s11606-021-06903-5DOI Listing
June 2021

Cigarette Smoking and Risk Perceptions During the COVID-19 Pandemic Reported by Recently Hospitalized Participants in a Smoking Cessation Trial.

J Gen Intern Med 2021 Jun 7. Epub 2021 Jun 7.

Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.

Background: Cigarette smoking is a risk factor for severe COVID-19 disease. Understanding smokers' responses to the pandemic will help assess its public health impact and inform future public health and provider messages to smokers.

Objective: To assess risk perceptions and change in tobacco use among current and former smokers during the COVID-19 pandemic.

Design: Cross-sectional survey conducted in May-July 2020 (55% response rate) PARTICIPANTS: 694 current and former daily smokers (mean age 53, 40% male, 78% white) who had been hospitalized pre-COVID-19 and enrolled into a smoking cessation clinical trial at hospitals in Massachusetts, Pennsylvania, and Tennessee.

Main Measures: Perceived risk of COVID-19 due to tobacco use; changes in tobacco consumption and interest in quitting tobacco use; self-reported quitting and relapse since January 2020.

Key Results: 68% (95% CI, 65-72%) of respondents believed that smoking increases the risk of contracting COVID-19 or having a more severe case. In adjusted analyses, perceived risk was higher in Massachusetts where COVID-19 had already surged than in Pennsylvania and Tennessee which were pre-surge during survey administration (AOR 1.56, 95% CI, 1.07-2.28). Higher perceived COVID-19 risk was associated with increased interest in quitting smoking (AOR 1.72, 95% CI 1.01-2.92). During the pandemic, 32% (95% CI, 27-37%) of smokers increased, 37% (95% CI, 33-42%) decreased, and 31% (95% CI, 26-35%) did not change their cigarette consumption. Increased smoking was associated with higher perceived stress (AOR 1.49, 95% CI 1.16-1.91). Overall, 11% (95% CI, 8-14%) of respondents who smoked in January 2020 (pre-COVID-19) had quit smoking at survey (mean, 6 months later) while 28% (95% CI, 22-34%) of former smokers relapsed. Higher perceived COVID-19 risk was associated with higher odds of quitting and lower odds of relapse.

Conclusions: Most smokers believed that smoking increased COVID-19 risk. Smokers' responses to the pandemic varied, with increased smoking related to stress and increased quitting associated with perceived COVID-19 vulnerability.
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http://dx.doi.org/10.1007/s11606-021-06913-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8183588PMC
June 2021

Automated Behavioral Workplace Intervention to Prevent Weight Gain and Improve Diet: The ChooseWell 365 Randomized Clinical Trial.

JAMA Netw Open 2021 Jun 1;4(6):e2112528. Epub 2021 Jun 1.

Harvard Medical School, Boston, Massachusetts.

Importance: Personalized interventions that leverage workplace data and environments could improve effectiveness, sustainability, and scalability of employee wellness programs.

Objective: To test an automated behavioral intervention to prevent weight gain and improve diet using employee cafeteria purchasing data.

Design, Setting, And Participants: This individual-level randomized clinical trial of a 12-month intervention with 12 months of follow-up was conducted among employees of a hospital in Boston, Massachusetts, who purchased food at on-site cafeterias that used traffic-light labels (ie, green indicates healthy; yellow, less healthy; red, unhealthy). Participants were enrolled September 2016 to February 2018. Data were analyzed from May to September 2020.

Interventions: For 12 months, participants in the intervention group received 2 emails per week with feedback on previous cafeteria purchases and personalized health and lifestyle tips and 1 letter per month with peer comparisons and financial incentives for healthier purchases. Emails and letters were automatically generated using survey, health, and cafeteria data. Control group participants received 1 letter per month with general healthy lifestyle information.

Main Outcomes And Measures: The main outcome was change in weight from baseline to 12 months and 24 months of follow-up. Secondary outcomes included changes in cafeteria purchases, including proportion of green- and red-labeled purchases and calories purchased per day, from baseline (12 months preintervention) to the intervention (months 1-12) and follow-up (months 13-24) periods. Baseline Healthy Eating Index-15 (HEI-15) scores were compared to HEI-15 scores at 6, 12, and 24 months.

Results: Among 602 employees enrolled (mean [SD] age, 43.6 [12.2] years; 478 [79.4%] women), 299 were randomized to the intervention group and 303 were randomized to the control group. Baseline mean (SD) body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) was 28.3 (6.6) and HEI-15 score was 60.4 (12.4). There were no between-group differences in weight change at 12 (0.2 [95% CI, -0.6 to 1.0] kg) or 24 (0.6 [95% CI, -0.3 to 1.4] kg) months. Compared with baseline, the intervention group increased green-labeled purchases by 7.3% (95% CI, 5.4% to 9.3%) and decreased red-labeled purchases by 3.9% (95% CI, -5.0% to -2.7%) and calories purchased per day by 49.5 (95% CI, -75.2 to -23.9) kcal more than the control group during the intervention period. In the intervention group, differences in changes in green (4.8% [95% CI, 2.9% to 6.8%]) and red purchases (-3.1% [95% CI, -4.3% to -2.0%]) were sustained at the 24-month follow-up. Differences in changes in HEI-15 scores were not significantly different in the intervention compared with the control group at 6 (2.2 [95% CI, 0 to 4.4]), 12 (1.8 [95% CI, -0.6 to 4.1]), and 24 (1.6, 95% CI, -0.7 to 3.8]) months.

Conclusions And Relevance: The findings of this randomized clinical trial suggest that an automated behavioral intervention using workplace cafeteria data improved employees' food choices but did not prevent weight gain over 2 years.

Trial Registration: ClinicalTrials.gov Identifier: NCT02660086.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.12528DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8185595PMC
June 2021

Correlating Burnout and Well-being in a Multisite Study of Internal Medicine Residents and Faculty.

J Gen Intern Med 2021 05 5;36(5):1422-1426. Epub 2021 Mar 5.

Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.

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http://dx.doi.org/10.1007/s11606-021-06653-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8131435PMC
May 2021

Evaluating the SPIKES Model for Improving Peer-to-Peer Feedback Among Internal Medicine Residents: a Randomized Controlled Trial.

J Gen Intern Med 2021 Jan 27. Epub 2021 Jan 27.

Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.

Background: Feedback improves trainee clinical performance, but the optimal way to provide it remains unclear. Peer feedback offers unique advantages but comes with significant challenges including a lack of rigorously studied methods. The SPIKES framework is a communication tool adapted from the oncology and palliative care literature for teaching trainees how to lead difficult conversations.

Objective: To determine if a brief educational intervention focused on the SPIKES framework improves peer feedback between internal medicine trainees on inpatient medicine services as compared to usual practice.

Design: Randomized, controlled trial at an academic medical center during academic year 2017-2018.

Participants: Seventy-five PGY1 and 49 PGY2 internal medicine trainees were enrolled. PGY2s were randomized 1:1 to the intervention or control group.

Intervention: The intervention entailed a 30-min, case-based didactic on the SPIKES framework followed by a refresher email on SPIKES sent to PGY2s before each inpatient medicine rotation. PGY1s were blinded as to which PGY2s underwent the training.

Main Measures: The primary outcome was PGY1 evaluation of the extent of feedback provided by PGY2s. Secondary outcomes included PGY1 report of feedback quality and PGY2 self-report of feedback quantity and quality. Outcomes were obtained via anonymous online survey and reported using a Likert scale with a range of one to four.

Key Results: PGY1s completed 207 surveys (51% response rate) and PGY2s completed 61 surveys (42% response rate). PGY1s reported a higher extent of feedback (2.5 vs 2.2; p = 0.02; Cohen's d = 0.31), more specific feedback (2.3 vs 2.0; p < 0.01; d = 0.33), and higher satisfaction with feedback (2.6 vs 2.2; p < 0.01; d = 0.47) from intervention PGY2s. There were no significant differences in PGY2 self-reported outcomes.

Conclusions: With modest implementation requirements and notable limitations, a brief educational intervention focused on SPIKES increased PGY1 perception of the extent, specificity, and satisfaction with feedback from PGY2s.
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http://dx.doi.org/10.1007/s11606-020-06459-wDOI Listing
January 2021

Meniscal and Mechanical Symptoms Are Associated with Cartilage Damage, Not Meniscal Pathology.

J Bone Joint Surg Am 2021 Mar;103(5):381-388

Department of Orthopaedic Surgery (E.M.F., N.A.L., J.N.K., and E.G.M.) and the Orthopedic and Arthritis Center for Outcomes Research (Y.C., K.R.A., and J.N.K.), Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.

Background: Traditionally defined "meniscal" and "mechanical" symptoms are thought to arise from meniscal tears. Yet meniscal tears and cartilage damage commonly coexist in symptomatic knees. To better characterize the primary driver of these symptoms, we investigated whether the presence of preoperative patient-reported knee symptoms (PRKS), including knee catching/locking, grinding/clicking/popping, and pain with pivoting, are associated with various intra-articular pathological conditions diagnosed at knee arthroscopy.

Methods: We collected prospective data from 565 consecutive patients who underwent knee arthroscopy from 2012 to 2019 and had PRKS collected via the Knee injury and Osteoarthritis Outcome Score (KOOS) questionnaire. The diagnosis of meniscal pathology and concomitant cartilage damage was confirmed and classified intraoperatively. We used multivariable regression models, adjusting for possible confounders, to examine the association of specific pathological conditions of the knee with the presence of preoperative PRKS.

Results: Tricompartmental cartilage damage was strongly associated with significantly worse PRKS, with an increase of 0.33 point (95% confidence interval [CI] = 0.08 to 0.58; p = 0.01) on a 0 to 4-point scale. We did not observe an association between meniscal pathology and preoperative PRKS.

Conclusions: Contrary to current dogma, this study demonstrates that traditionally defined "meniscal" and "mechanical" knee symptoms are strongly associated with the burden and severity of underlying cartilage damage rather than with specific meniscal pathology.

Level Of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.2106/JBJS.20.01193DOI Listing
March 2021

The roles and clinical activities of registered nurses and nurse practitioners in practices caring for older adults.

Nurs Outlook 2021 May-Jun;69(3):380-388. Epub 2021 Jan 6.

Harvard Medical School, Health Policy Research Center, The Mongan Institute, Massachusetts General Hospital, Boston, MA.

Background: Population aging and physician shortages have motivated recommendations of increased use of registered nurses in care provision; little is known about RN and NP employment in primary care and geriatric practices or service types each provide.

Purpose: Determine current RN and NP employment frequency in practices in the U.S., identify services provided by RNs, and whether NP presence in practice is associated with the types and frequency of services provided by RNs.

Methods: National survey of 410 primary care and geriatric clinicians.

Findings: Only half of practices employed RNs. RNs most frequently provide teaching or education for chronic disease management. RNs provide significantly more primary care and geriatric services when practices employed a NP.

Discussion: Reasons for RN underuse in practices should be identified, clinical placements in such practices should increase, and NP education programs should include care models using RNs to their full scope of practice.
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http://dx.doi.org/10.1016/j.outlook.2020.11.011DOI Listing
January 2021

National utilization and inpatient safety measures of lumbar spinal fusion methods by race/ethnicity.

Spine J 2021 05 20;21(5):785-794. Epub 2020 Nov 20.

Harvard Medical School, 25 Shattuck St, Boston, MA 02115 USA; Division of General Medicine, Massachusetts General Hospital, 50 Staniford St, 9th floor, Boston, MA 02114 USA.

Background Context: Degenerative lumbar conditions are prevalent, disabling, and frequently managed with decompression and fusion. Black patients have lower spinal fusion rates than White patients.

Purpose: Determine whether specific lumbar fusion procedure utilization differs by race/ethnicity and whether length of stay (LOS) or inpatient complications differ by race/ethnicity after accounting for procedure performed.

Study Design: Large database retrospective cohort study PATIENT SAMPLE: Lumbar fusion recipients at least age 50 in the 2016 National Inpatient Sample with diagnoses of degenerative lumbar conditions.

Outcome Measures: Type of fusion procedure used and inpatient safety measures including LOS, prolonged LOS, inpatient medical and surgical complications, mortality, and cost.

Methods: We examined the association between race/ethnicity and the safety measures above. Covariates included several patient and hospital factors. We used multiple linear or logistic regression to determine the association between race and fusion type (PLF, P/TLIF, ALIF, PLF + P/TLIF, and PLF + ALIF [anterior-posterior fusion]) and to determine whether race was associated independently with inpatient safety measures, after adjustment for patient and hospital factors.

Results: Fusion method use did not differ among racial/ethnic groups, except for somewhat lower anterior-posterior fusion utilization in Black patients compared to White patients (crude odds ratio [OR]: 0.81 [0.67-0.97]). Inpatient safety measures differed by race/ethnicity for rates of prolonged LOS (Blacks 18.1%, Hispanics 14.5%, and Whites 11.7%), medical complications (Blacks 9.9%, Hispanics 8.7%, and Whites 7.7%), and surgical complications (Blacks 5.2%, Hispanics 6.9%, and Whites 5.4%). Differences persisted after adjustment for procedure type as well as patient and hospital factors. Blacks and Hispanics had higher risk for prolonged LOS compared to Whites (adjusted OR Blacks 1.39 [95% confidence interval {CI} 1.22-1.59]; Hispanics 1.24 [95% CI 1.02-1.52]). Blacks had higher risk for inpatient medical complications compared to Whites (adjusted OR 1.24 [95% CI 1.05-1.48]), and Hispanics had higher risk for inpatient surgical complications compared to Whites (adjusted OR 1.34 [95% CI 1.06-1.68]).

Conclusions: Fusion method use was generally similar between racial/ethnic groups. Inpatient safety measures, adjusted for procedure type, patient and hospital factors, were worse for Blacks and Hispanics.
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http://dx.doi.org/10.1016/j.spinee.2020.11.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8113062PMC
May 2021

Does the effect of lifestyle intervention for individuals with diabetes vary by food insecurity status? A preplanned subgroup analysis of the REAL HEALTH randomized clinical trial.

BMJ Open Diabetes Res Care 2020 09;8(1)

Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA

Introduction: We aimed to test the effectiveness of a lifestyle intervention (LI) for individuals with food insecurity and type 2 diabetes.

Research Design And Methods: Adults with type 2 diabetes, body mass index ≥25 kg/m (or ≥23 kg/m if Asian), hemoglobin A1c of 6.5%-11.5% (48-97 mmol/mol) and who were willing to lose 5%-7% bodyweight were enrolled in REAL HEALTH-Diabetes. This practice-based randomized clinical trial compared LI (delivered inperson or by telephone) with medical nutrition therapy (MNT) on weight loss at 6 and 12 months. Two or more affirmative responses on the six-item US Department of Agriculture Food Security Survey Module indicated food insecurity. In this prespecified subgroup analysis, we tested using linear mixed effects models whether the intervention effect varied by food security status.

Results: Of 208 participants, 13% were food insecure. Those with food insecurity were more likely to be racial/ethnic minorities (p<0.001) and have lower education (p<0.001). LI, versus MNT, led to greater weight loss at 6 months (5.1% lost vs 1.1% lost; p<0.0001) and 12 months (4.7% lost vs 2.0% lost; p=0.0005). The intervention effect was similar regardless of food security status (5.1% bodyweight lost vs 1.1% in food secure participants and 5.1% bodyweight lost vs 1.3% in food insecure participants at 6 months; 4.7% bodyweight lost vs 2.1% in food secure participants and 4.5% bodyweight lost vs 0.9% in food insecure participants at 12 months; p for interaction=0.99).

Conclusions: The REAL HEALTH-Diabetes lifestyle intervention led to meaningful weight loss for individuals with food insecurity and type 2 diabetes.

Trial Registration Number: NCT02320253.
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http://dx.doi.org/10.1136/bmjdrc-2020-001514DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7520816PMC
September 2020

Impact of reported NSAID "allergies" on opioid use disorder in back pain.

J Allergy Clin Immunol 2021 Apr 9;147(4):1413-1419. Epub 2020 Sep 9.

Division of Allergy and Clinical Immunology, Department of Medicine, Brigham and Women's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass.

Background: It is crucial to identify patients at highest risk for opioid use disorder (OUD) and to address challenges in reducing opioid use. Reported nonsteroidal anti-inflammatory drug (NSAID) allergies may predispose to use of stronger pain medications and potentially to OUD.

Objective: We sought to investigate the clinical impact of reported NSAID allergy on OUD in patients with chronic back pain.

Methods: We conducted a retrospective study of adults receiving care at a tertiary health care system from January 1, 2013, to December 31, 2018. Back pain and OUD were identified using administrative data algorithms. We used propensity score matching and logistic regression to estimate the impact of self-reported NSAID adverse drug reactions (ADRs) on risk of OUD, adjusting for other relevant clinical information.

Results: Of 47,114 patients with chronic back pain, 3,620 (7.7%) had a reported NSAID ADR. In an adjusted propensity score-matched analysis, patients with NSAID ADRs had higher odds (odds ratio, 1.34; 95% CI, 1.07-1.67) of developing OUD as compared with those without NSAID ADRs. Additional risk factors for OUD included younger age, male sex, Medicaid insurance, Medicare insurance, higher number of inpatient and outpatient visits in the previous year, and comorbid anxiety and depression. Patients with listed NSAID ADRs also had higher odds of a documented opioid prescription during the study period (odds ratio, 1.22; 95% CI, 1.11-1.34).

Conclusions: Adults with chronic back pain and reported NSAID ADRs are at a higher risk of developing OUD and receiving opioid analgesics, even after accounting for comorbidities and health care utilization. Allergy evaluation is critical for potential delabeling of patients with reported NSAID allergies and chronic pain.
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http://dx.doi.org/10.1016/j.jaci.2020.08.025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7995999PMC
April 2021

The effectiveness of post-discharge navigation added to an inpatient addiction consultation for patients with substance use disorder; a randomized controlled trial.

Subst Abus 2020 Sep 3:1-8. Epub 2020 Sep 3.

Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.

Background: It is unknown whether post-discharge navigation enhances the impact of hospital-initiated addiction care. This study tested the incremental benefit of telephonic linkage to a post-discharge navigator for patients who received an addiction consultation during hospitalization. A two-arm, randomized controlled trial of 395 hospitalized adults with substance use disorder who received an addiction consultation. The intervention group received post-discharge phone calls from a navigator to review the recommended treatment plan and address barriers to engagement on days 3, 7, 14, and 21. The primary outcome was days of alcohol or drug use in the past 30 assessed by Timeline Follow-back at 1 month. : Follow-up assessment completion rates were 46% at 1 month, and 41%, at 2 months. At baseline, intervention and control groups did not differ in substance use patterns; 45% reported primary alcohol use, 43% drugs, and 12% both. Heroin was the most common drug. At baseline, mean days of past 30-day alcohol or drug use were 13.6 in the intervention and 14.9 in the control group. The median number of navigation calls completed was 3 out of 4. At 1 month, both groups reported less use (decrease of 4.8 in intervention vs. 4.2 days in control group,  = 0.49). There were no differences between groups at 2 months. Compared to controls, participants who received all four calls had a greater decrease in use with a mean 8.6 days decrease from baseline (difference of 4.4 days,  = 0.0009). : Post-discharge telephonic patient navigation did not further improve substance use outcomes following addiction consultation.
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http://dx.doi.org/10.1080/08897077.2020.1809608DOI Listing
September 2020

Advance Care Planning: Promoting Effective and Aligned Communication in the Elderly (ACP-PEACE): the study protocol for a pragmatic stepped-wedge trial of older patients with cancer.

BMJ Open 2020 07 14;10(7):e040999. Epub 2020 Jul 14.

Harvard Medical School, Boston, Massachusetts, USA.

Introduction: Advance care planning (ACP) is associated with improved health outcomes for patients with cancer, and its absence is associated with unfavourable outcomes for patients and their caregivers. However, older adults do not complete ACP at expected rates due to patient and clinician barriers. We present the original design, methods and rationale for a trial aimed at improving ACP for older patients with advanced cancer and the modified protocol in response to changes brought by the COVID-19 pandemic.

Methods And Analysis: The Advance Care Planning: Promoting Effective and Aligned Communication in the Elderly study is a pragmatic, stepped-wedge cluster randomised trial examining a Comprehensive ACP Program. The programme combines two complementary evidence-based interventions: clinician communication skills training (VitalTalk) and patient video decision aids (ACP Decisions). We will implement the programme at 36 oncology clinics across three unique US health systems. Our primary outcome is the proportion of eligible patients with ACP documentation completed in the electronic health record. Our secondary outcomes include resuscitation preferences, palliative care consultations, death, hospice use and final cancer-directed therapy. From a subset of our patient population, we will collect surveys and video-based declarations of goals and preferences. We estimate 11 000 patients from the three sites will be enrolled in the study.

Ethics And Dissemination: Regulatory and ethical aspects of this trial include Institutional Review Board (IRB) approval via single IRB of record mechanism at Dana-Farber Cancer Institute, Data Use Agreements among partners and a Data Safety and Monitoring Board. We plan to present findings at national meetings and publish the results.

Trial Registration Number: NCT03609177; Pre-results.
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http://dx.doi.org/10.1136/bmjopen-2020-040999DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7365491PMC
July 2020

Care Plans, Care Teams, and Quality of Life for People with Disabilities.

J Gen Intern Med 2020 08 9;35(8):2274-2280. Epub 2020 Jun 9.

Health Policy Research Center, The Mongan Institute, Massachusetts General Hospital , Boston, MA, USA.

Background: Massachusetts One Care was the first program approved among the Centers for Medicare & Medicaid Financial Alignment Demonstrations for dually eligible beneficiaries. The only program focusing on dually eligible beneficiaries ages 21-64, One Care espouses an independent living philosophy for persons with disabilities. Researchers engaged with enrollees to develop new measures of enrollee quality of life and health to understand changes experienced in this new model of care.

Objective: To examine whether enrollee knowledge of care plans and care teams predicts improvements in enrollee reported quality of life outcomes.

Design And Participants: We engaged with people with disabilities to develop and implement a longitudinal survey in One Care in Massachusetts. This analysis presents the self-reported outcomes of a panel of 315 enrollees' experiences with key plan features in Massachusetts One Care enrollees.

Main Measures: Knowledge of care plan, care team, and long-term services and supports (predictors); overall health, improved control, improved quality of health care, and improved hope for the future (outcomes).

Key Results: Enrollee-reported knowledge of a care plan and a care team over 2 years of enrollment in Massachusetts One Care was associated with increased odds of reporting more control over health (OR 2.58, CI 1.33, 5.03), improved health care quality (OR 3, CI 1.27, 7.06), and overall health (OR 2.07, CI 1.05, 4.08). Access to new services or equipment to live independently was associated with increased odds of reporting all four positive outcomes, notably for improved perceptions of hope (OR 2.33, CI 1.56, 5.39), overall health (OR 5.03, CI 2.44, 10.39), and improved quality of care (OR 4.22, CI 1.85, 9.62).

Conclusion: Engagement of persons with disabilities in care teams and care planning, as well as quality measurement, can improve their experiences of quality of life and health care.
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http://dx.doi.org/10.1007/s11606-020-05908-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7403261PMC
August 2020

Comparative effectiveness of post-discharge strategies for hospitalized smokers: Study protocol for the Helping HAND 4 randomized controlled trial.

Trials 2020 Apr 16;21(1):336. Epub 2020 Apr 16.

Vanderbilt University Medical Center, Nashville, TN, USA.

Background: Tobacco smoking remains the leading preventable cause of death in the US. A hospital admission provides smokers with a unique opportunity to stop smoking because it requires temporary tobacco abstinence while illness may enhance motivation to quit. Hospital interventions must continue post-discharge to increase tobacco abstinence long-term, but how best to accomplish this remains unclear. Building on two previous randomized controlled trials, each of which tested smoking cessation interventions that began in hospital and continued after discharge, this trial compares two interventions that provide sustained smoking cessation treatment after hospital discharge with the goal of improving long-term smoking cessation rates among hospitalized smokers.

Methods/design: Helping HAND 4 is a three-site randomized controlled trial that compares the effectiveness of two active interventions for producing validated past 7-day tobacco abstinence 6 months after hospital discharge. Smokers who are admitted to three hospitals receive a standard in-hospital smoking intervention, and those who plan to quit smoking after discharge are recruited and randomly assigned to two interventions that begin at discharge, Personalized Tobacco Care Management (PTCM) or Quitline eReferral. Each lasts 3 months. At discharge, PTCM provides 8 weeks of free nicotine replacement (NRT; a participant's choice of patch, gum, lozenge, or a combination) and then proactive smoking cessation support using an automated communication platform and live contact with a tobacco treatment specialist who is based in the health care system. In the eReferral condition, a direct referral is made from the hospital electronic health record to a community-based resource, the state's telephone quitline. The quitline provides up to 8 weeks of free NRT and offers behavioral support via a series of phone calls from a trained coach. Outcomes are assessed at 1, 3, and 6 months after discharge. The study hypothesis is that PTCM will produce higher quit rates than eReferral.

Discussion: Helping HAND 4 is a pragmatic trial that aims to evaluate interventions in real-world conditions. This project will give hospital systems critical evidence-based tools for meeting National Hospital Quality Measures for tobacco treatment and maximizing their ability to improve cessation rates and overall health for the millions of smokers hospitalized annually in the US.

Trial Registration: Prospectively registered prior to start of enrollment at Clinicaltrials.gov, NCT03603496 (July 27, 2018). https://register.clinicaltrials.gov/prs/app/action/SelectProtocol?sid=S00084MJ&selectaction=Edit&uid=U00002G7&ts=2&cx=ff0oxn.
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http://dx.doi.org/10.1186/s13063-020-04257-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7164139PMC
April 2020

Phenobarbital for Acute Alcohol Withdrawal Management in Surgical Trauma Patients-A Retrospective Comparison Study.

Psychosomatics 2020 Jul - Aug;61(4):327-335. Epub 2020 Feb 8.

Trauma, Emergency Surgery and Surgical Critical Care Service, Massachusetts General Hospital, Boston, MA.

Background: Alcohol withdrawal syndrome (AWS) in surgical trauma patients is associated with significant morbidity and mortality. Benzodiazepines, commonly used for withdrawal management, pose unique challenges in this population given the high prevalence of head trauma and delirium. Phenobarbital is an antiepileptic drug that offers a viable alternative to benzodiazepines for AWS treatment.

Methods: This is a retrospective chart review of patients with active alcohol use disorder who presented to a level 1 trauma center over a 4-year period and required medication-assisted management for AWS. The primary outcome variable examined was the development of AWS and associated complications. Additional outcomes measured included hospital length of stay, mortality, and medication-related adverse events.

Results: Of the 85 patients in the study sample, 52 received a fixed-dose benzodiazepine-based protocol and 33 received phenobarbital-based protocol. In the benzodiazepine-based protocol group, 25 patients (48.2%) developed AWD and 38 (73.1%) developed uncomplicated AWS, as compared to 0 patients in the phenobarbital-based protocol (P = 0.0001). There were 10 (19.2%) patients with medication adverse side effects in the benzodiazepine-based protocol group versus 0 patients in the phenobarbital-based protocol group. There were no statically significant differences between the 2 groups as pertains to rates of other AWS-related complications, patient mortality, or length of stay.

Conclusion: The use of a phenobarbital-based protocol in trauma patients with underlying active alcohol use disorder resulted in a statistically significant decrease in the incidence of AWD and uncomplicated AWS secondary to AWS when compared to patients treated with a fixed-dose benzodiazepine-based protocol.
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http://dx.doi.org/10.1016/j.psym.2020.01.008DOI Listing
July 2021

Proactively Offered Text Messages and Mailed Nicotine Replacement Therapy for Smokers in Primary Care Practices: A Pilot Randomized Trial.

Nicotine Tob Res 2020 08;22(9):1509-1514

Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA.

Introduction: Proactive, population health cessation programs can guide efforts to reach smokers outside of the clinic to encourage quit attempts and treatment use.

Aims And Methods: This study aimed to measure trial feasibility and preliminary effects of a proactive intervention offering text messages (TM) and/or mailed nicotine replacement therapy (NRT) to smokers in primary care clinics. From 2017 to 2019 we performed a pilot randomized trial comparing brief telephone advice (control: BA), TM, 2 weeks of mailed NRT, or both interventions (TM + NRT). Patients were identified using electronic health records and contacted proactively by telephone to assess interest in the study. We compared quit attempts, treatment use, and cessation in the intervention arms with BA.

Results: Of 986 patients contacted, 153 (16%) enrolled (mean age 53 years, 57% female, 76% white, 11% black, 8% Hispanic, 52% insured by Medicaid) and 144 (94%) completed the 12-week assessment. On average, patients in the TM arms received 159 messages (99.4% sent, 0.6% failed), sent 19 messages, and stayed in the program for 61 days. In all groups, a majority of patients reported quit attempts (BA 67% vs. TM 86% [p = .07], NRT 81% [p = .18], TM + NRT 79% [p = .21]) and NRT use (BA 51% vs. NRT 83% [p = .007], TM 65% [p = .25], TM + NRT 76% [p = .03]). Effect estimates for reported 7-day abstinence were BA 10% versus TM 26% (p = .09), NRT 28% (p = .06), and TM + NRT 23% (p = .14).

Conclusions: Proactively offering TM or mailed nicotine medications was feasible among primary care smokers and a promising approach to promote quit attempts and short-term abstinence.

Implications: Proactive intervention programs to promote quit attempts outside of office visits among smokers enrolled in primary care practices are needed. TM have potential to engage smokers not planning to quit or to support smokers to make a planned quit attempt. This pilot study demonstrates the feasibility of testing a proactive treatment model including TM and/or mailed NRT to promote quit attempts, treatment use, and cessation among nontreatment-seeking smokers in primary care.

Clinicaltrials.gov Identifier: NCT03174158.
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http://dx.doi.org/10.1093/ntr/ntaa050DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7443591PMC
August 2020

Correction to: Online Searches for Quitting Vaping During the 2019 Outbreak of E-cigarette or Vaping Product Use-Associated Lung Injury.

J Gen Intern Med 2020 Mar 6. Epub 2020 Mar 6.

Tobacco Research and Treatment Center, Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA.

This paper was originally published with an incorrect title.
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http://dx.doi.org/10.1007/s11606-020-05753-xDOI Listing
March 2020

A multidisciplinary approach to decreasing length of stay in acute care surgery patients.

J Adv Nurs 2020 Jun 26;76(6):1364-1370. Epub 2020 Mar 26.

Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA.

Aim: To decrease hospital length of stay in acute care surgery patients.

Design: An observational cohort quality improvement project at a single tertiary referral centre.

Methods: A multidisciplinary team of physicians, nurses, case managers, and physical and occupational therapists was created to identify patients at risk for prolonged length of stay and implement weekly multidisciplinary rounding, with a systematic method of tracking progress in real time. The main outcome measure was hospital length of stay. The observed/expected ratios for length of stay 2 years before (2012-2014) and after (2014-2016) the intervention were compared.

Results: A total of 6,120 patients was analysed. Early identification and action on barriers to discharge created a significant decrease in risk-adjusted acute care surgery patient days per year (96 days) with limited added cost (1-2 hr per week). Patients discharged to home with or without services benefited most.

Conclusion: Decreasing length of stay in acute care surgery patients is possible without adding a significant burden to healthcare providers.

Impact: We describe a comprehensive, multidisciplinary initiative to decrease the length of stay of acute care surgery patients. Institutions can use existing resources in a sustainable manner to create a significant decrease in patient days per year with limited added cost. REGISTRATION: https://osf.io/zfc3t.
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http://dx.doi.org/10.1111/jan.14335DOI Listing
June 2020

Online Searches for Quitting Vaping During the 2019 Outbreak of E-cigarette or Vaping Product Use-Associated Lung Injury.

J Gen Intern Med 2021 02 12;36(2):559-560. Epub 2020 Feb 12.

Tobacco Research and Treatment Center, Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA.

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http://dx.doi.org/10.1007/s11606-020-05686-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7878629PMC
February 2021

Effectiveness of Lifestyle Intervention for Type 2 Diabetes in Primary Care: the REAL HEALTH-Diabetes Randomized Clinical Trial.

J Gen Intern Med 2020 09 21;35(9):2637-2646. Epub 2020 Jan 21.

Diabetes Unit, Department of Medicine, Massachusetts General Hospital (MGH) Diabetes Research Center, Boston, MA, USA.

Background: Intensive lifestyle interventions (LI) improve outcomes in obesity and type 2 diabetes but are not currently available in usual care.

Objective: To compare the effectiveness and costs of two group LI programs, in-person LI and telephone conference call (telephone LI), to medical nutrition therapy (MNT) on weight loss in primary care patients with type 2 diabetes.

Design: A randomized, assessor-blinded, practice-based clinical trial in three community health centers and one hospital-based practice affiliated with a single health system.

Participants: A total of 208 primary care patients with type 2 diabetes, HbA1c 6.5 to < 11.5, and BMI > 25 kg/m (> 23 kg/m in Asians).

Interventions: Dietitian-delivered in-person or telephone group LI programs with medication management or MNT referral.

Main Measures: Primary outcome: mean percent weight change.

Secondary Outcomes: 5% and 10% weight loss, change in HbA1c, and cost per kilogram lost.

Key Results: Participants' mean age was 62 (SD 10) years, 45% were male, and 77% were White, with BMI 35 (SD 5) kg/m and HbA1c 7.7 (SD 1.2). Seventy were assigned to in-person LI, 72 to telephone LI, and 69 to MNT. The mean percent weight loss (95% CI) at 6 and 12 months was 5.6% (4.4-6.8%) and 4.6% (3.1-6.1%) for in-person LI, 4.6% (3.3-6.0%) and 4.8% (3.3-6.2%) for telephone LI, and 1.1% (0.2-2.0%) and 2.0% (0.9-3.0%) for MNT, with statistically significant differences between each LI arm and MNT (P < 0.001) but not between LI arms (P = 0.63). HbA1c improved in all participants. Compared with MNT, the incremental cost per kilogram lost was $789 for in-person LI and $1223 for telephone LI.

Conclusions: In-person LI or telephone group LI can achieve good weight loss outcomes in primary care type 2 diabetes patients at a reasonable cost.

Clinical Trial Registration: ClinicalTrials.gov Identifier: NCT02320253.
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http://dx.doi.org/10.1007/s11606-019-05629-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7458982PMC
September 2020

Impact on Length of Stay of a Hospital Medicine Emergency Department Boarder Service.

J Hosp Med 2019 Nov 20;14:E1-E7. Epub 2019 Nov 20.

Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.

Background: It is not known whether delivering inpatient care earlier to patients boarding in the emergency department (ED) by a hospitalist-led team can decrease length of stay (LOS).

Objective: To study the association between care provided by a hospital medicine ED Boarder (EDB) service and LOS.

Design, Setting, And Participants: Retrospective cross-sectional study (July 1, 2016 to June 30, 2018) conducted at a single, large, urban academic medical center. Patients admitted to general medicine services from the ED were included. EDB patients were defined as those waiting for more than two hours for an inpatient bed. Patients were categorized as covered EDB, noncovered EDB, or nonboarder.

Intervention: The hospital medicine team provided continuous care to covered EDB patients waiting for an inpatient bed.

Primary Outcome And Measures: The primary outcome was median hospital LOS defined as the time period from ED arrival to hospital departure. Secondary outcomes included ED LOS and 30-day ED readmission rate.

Results: There were 8,776 covered EDB, 5,866 noncovered EDB, and 2,026 nonboarder patients. The EDB service covered 59.9% of eligible patients and 62.9% of total boarding hours. Median hospital LOS was 4.76 (interquartile range [IQR] 2.90-7.22) days for nonboarders, 4.92 (IQR 3.00-8.03) days for covered EDB patients, and 5.11 (IQR 3.16-8.34) days for noncovered EDB (P < .001). Median ED LOS for nonboarders was 5.6 (IQR 4.2-7.5) hours, 20.7 (IQR 15.8-24.9) hours for covered EDB, and 10.1 (IQR 7.9-13.8) hours for noncovered EDB (P < .001). There was no difference in 30-day ED readmission rates.

Conclusion: Admitted patients who were not boarders had the shortest LOS. Among boarded patients, coverage by a hospital medicine-led EDB service was associated with a reduced hospital LOS.
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http://dx.doi.org/10.12788/jhm.3337DOI Listing
November 2019

E-cigarettes and Smoking Cessation in Smokers With Chronic Conditions.

Am J Prev Med 2019 12;57(6):786-791

Tobacco Research and Treatment Center, Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.

Introduction: Many smokers with chronic medical conditions use e-cigarettes. This study assessed the association between e-cigarette use and subsequent smoking-cessation efforts in adult smokers with and without chronic medical conditions.

Methods: This was a longitudinal cohort study of adult cigarette smokers using Waves 1 and 2 of the Population Assessment of Tobacco and Health Study (2013-2015), analyzed in 2018‒2019. The exposure was the initiation of e-cigarette use by Wave 2. The outcomes at Wave 2 were: (1) past 12-month attempts to quit, (2) cigarette abstinence, (3) ≥50% reduction in cigarette use, and (4) past 12-month use of evidence-based smoking-cessation treatment.

Results: E-cigarette use initiation was associated with increased odds of attempting to quit smoking at Wave 2 among smokers with any chronic medical condition (AOR=1.92, 95% CI=1.42, 2.59) and without chronic medical conditions (AOR=1.81, 95% CI=1.50, 2.18). E-cigarette use initiation was also significantly associated with Wave 2 smoking abstinence in smokers with (AOR=1.95, 95% CI=1.11, 3.43) and without chronic medical conditions (AOR=1.63, 95% CI=1.17, 2.28).

Conclusions: At a population level, e-cigarette use by smokers with chronic medical conditions is associated with more quitting activity and smoking abstinence. Future studies are needed to assess e-cigarette safety and efficacy to determine whether they may provide an alternative smoking-cessation or harm-reduction strategy for adults with smoking-sensitive disease who cannot achieve these goals with other methods.
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http://dx.doi.org/10.1016/j.amepre.2019.08.017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6876707PMC
December 2019

Resident identification of feedback and teaching on rounds.

Proc (Bayl Univ Med Cent) 2019 Oct 5;32(4):525-528. Epub 2019 Aug 5.

Department of Medicine, Massachusetts General HospitalBostonMassachusetts.

Feedback and teaching occur regularly on teaching hospital wards. Although feedback has important implications for resident learning, residents often report that they receive little feedback. The significant overlap of teaching and feedback in clinical education may contribute to resident difficulty with feedback identification. We sent a survey with seven scenarios to internal medicine residents across the country. Two of the scenarios contained teaching, two contained feedback, and three contained combined teaching and feedback. From October 2017 to April 2018, 17% of residents (392/2346) from 17 residency programs completed the survey. Participating residents correctly identified both feedback scenarios 89% of the time, both teaching scenarios 64% of the time, and all three combined teaching and feedback scenarios 38% of the time. Interns were less likely than upper-level residents to correctly identify combined teaching and feedback scenarios ( = 0.005). Residents may have difficulty identifying feedback in the context of teaching. This confusion may contribute to residents' perceptions that they receive little feedback.
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http://dx.doi.org/10.1080/08998280.2019.1641046DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6793959PMC
October 2019

Response to: A Source of Bias in Studies of E-cigarettes and Smoking Cessation.

Nicotine Tob Res 2020 04;22(5):863

Tobacco Research and Treatment Center, Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA.

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http://dx.doi.org/10.1093/ntr/ntz152DOI Listing
April 2020

Impact of Timing on Measurement of Decision Quality and Shared Decision Making: Longitudinal Cohort Study of Breast Cancer Patients.

Med Decis Making 2019 08 29;39(6):642-650. Epub 2019 Jul 29.

The Ohio State University, Columbus, OH, USA.

The objective of this study was to examine whether scores of shared decision-making measures differ when collected shortly after (1 month) or long after (1 year) breast cancer surgical treatment decisions. Longitudinal, multisite survey of breast cancer (BC) patients, with measurements at 1 month and 1 year after surgery at 4 cancer centers. Patients completed the BC Surgery Decision Quality Instrument (used to generate a knowledge score, ratings of goals, and concordance with treatment preferences) and Shared Decision Making (SDM) Process survey at both time points. We tested several hypotheses related to the scores over time, including whether the scores discriminated between sites that did and did not offer formal decision support services. Exploratory analyses examined factors associated with large increases and decreases in scores over time. Across the 4 sites, 229 patients completed both assessments. The mean total knowledge scores (69.2% [SD 16.6%] at 1 month and 69.4% [SD 17.7%] at 1 year, = 0.86), SDM Process scores (2.7 [SD 1.1] 1 month v. 2.7 [SD 1.2] 1 year, = 0.68), and the percentage of patients receiving their preferred treatment (92% at 1 month and 92% at 1 year, = 1.0) were not significantly different over time. The site using formal decision support had significantly higher knowledge and SDM Process scores at 1 month, and only the SDM Process scores remained significantly higher at 1 year. A significant percentage of patients had large changes in their individual knowledge and SDM Process scores, with increases balancing out decreases. For population-level assessments, it is reasonable to survey BC patients up to a year after the decision, greatly increasing feasibility of measurement. For those evaluating decision support interventions, shorter follow-up is more likely to detect an impact on knowledge scores.
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http://dx.doi.org/10.1177/0272989X19862545DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7240785PMC
August 2019

Design and rationale of a pragmatic trial integrating routine screening for atrial fibrillation at primary care visits: The VITAL-AF trial.

Am Heart J 2019 09 22;215:147-156. Epub 2019 Jun 22.

Cardiovascular Research Center and Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, MA. Electronic address:

Given the preventable morbidity and mortality associated with atrial fibrillation (AF), increased awareness of undiagnosed AF, and advances in mobile electrocardiogram (ECG) technology, there is a critical need to assess the effectiveness of using such technology to routinely screen for AF in clinical practice. VITAL-AF is a pragmatic trial that will test whether screening for AF using a single-lead handheld ECG in individuals 65 years or older during primary care visits will lead to an increased rate of AF detection. The study is a cluster-randomized trial, with 8 primary care practices randomized to AF screening and 8 primary care practices randomized to usual care. We anticipate studying approximately 16,000 patients in each arm. During the 1-year enrollment period, practice medical assistants will screen eligible patients who agree to participate during office visits using a single-lead ECG device. Automated screening results are documented in the electronic health record, and patients can discuss screening results with their provider during the scheduled visit. All single-lead ECGs are overread by a cardiologist. Screen-detected AF is managed at the discretion of the patient's physician. The primary study end point is incident AF during the screening period. Key secondary outcomes include new oral anticoagulation prescriptions, incident ischemic stroke, and major hemorrhage during a 24-month period following the study start. Outcomes are ascertained based on electronic health record documentation and are manually adjudicated. The results of this pragmatic trial may help identify a model for widespread adoption of AF screening as part of routine clinical practice.
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http://dx.doi.org/10.1016/j.ahj.2019.06.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7807527PMC
September 2019

Electronic Cigarette Use and Cigarette Abstinence Over 2 Years Among U.S. Smokers in the Population Assessment of Tobacco and Health Study.

Nicotine Tob Res 2020 04;22(5):728-733

Tobacco Research and Treatment Center, Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA.

Introduction: Electronic cigarettes (e-cigarettes) could benefit public health if they help current smokers to stop smoking long term, but evidence that they do so is limited. We aimed to determine the association between e-cigarette use and subsequent smoking cessation in a nationally representative cohort of US smokers followed for 2 years.

Methods: We analyzed data from adult cigarette smokers in Waves 1 through 3 of the Population Assessment of Tobacco and Health study. The primary exposure was e-cigarette use at Wave 1. The primary outcome was prolonged cigarette abstinence, defined as past 30-day cigarette abstinence at Waves 2 and 3 (1- and 2-year follow-up).

Results: Among Wave 1 cigarette smokers, 3.6% were current daily e-cigarette users, 18% were current non-daily e-cigarette users, and 78% reported no current e-cigarette use. In multivariable-adjusted analyses, daily e-cigarette use at Wave 1 was associated with higher odds of prolonged cigarette smoking abstinence at Waves 2 and 3 compared to nonuse of e-cigarettes (11% vs. 6%, adjusted odds ratio [AOR] = 1.77, 95% confidence interval [CI] = 1.08 to 2.89). Non-daily e-cigarette use was not associated with prolonged cigarette smoking abstinence. Among Wave 1 daily e-cigarette users who were abstinent from cigarette smoking at Wave 3, 63% were using e-cigarettes at Wave 3.

Conclusions: In this longitudinal cohort study of US adult cigarette smokers, daily but not non-daily e-cigarette use was associated with higher odds of prolonged cigarette smoking abstinence over 2 years, compared to no e-cigarette use. Daily use of e-cigarettes may help some smokers to stop smoking combustible cigarettes.

Implications: In this nationally representative longitudinal cohort study of US adult cigarette smokers, daily e-cigarette use, compared to no e-cigarette use, was associated with a 77% increased odds of prolonged cigarette smoking abstinence over the subsequent 2 years. Regular use of e-cigarettes may help some smokers to stop smoking combustible cigarettes.
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http://dx.doi.org/10.1093/ntr/ntz114DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7171267PMC
April 2020

Comparison of Three Measures of Shared Decision Making: SDM Process_4, CollaboRATE, and SURE Scales.

Med Decis Making 2019 08 21;39(6):673-680. Epub 2019 Jun 21.

Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA.

If shared decision making (SDM) is to be part of quality assessment, it is necessary to have good measures of SDM. The purpose of this study is to compare the psychometric performance of 3 short patient-reported measures of SDM. Patients who met with a specialist to discuss possible surgery for hip or knee osteoarthritis (hips/knees), lumbar herniated disc, or lumbar spinal stenosis (backs) were surveyed shortly after the visit and again 6 months later. Some of the patients saw a patient decision aid (PDA) prior to the meeting. The 3 SDM measures were the SDM Process_4 (SDMP) survey, CollaboRATE, and SURE scale. The follow-up survey included measures of decision regret, satisfaction, and decision quality. Patients in the sample ( = 649) had a mean age of 63.3 years, 51% were female, 60% were college educated, and there were more hip/knee patients than back patients (69% v. 31%). Forty-nine percent had surgery. For hips/knees, the SDMP and SURE scores were significantly associated with viewing all of the PDA compared with those who did not ( < 0.001), but not for CollaboRATE ( = 0.35). For backs, none of the scores were significantly associated with viewing all the PDA. All 3 scores were significantly associated with less regret and higher satisfaction ( < 0.001) for hips/knees. For backs, only SURE and CollaboRATE were significantly associated with less regret, and only SDMP was significantly associated with higher satisfaction. For hips/knees and backs, the SDMP and SURE scales were significantly associated with an informed patient-centered decision ( < 0.001), but this relationship was not significant for CollaboRATE (hips/knees: = 0.24; backs: = 0.25). Each measure has some evidence of validity. SURE and SDMP better discriminate the use of PDAs and have higher decision quality.
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http://dx.doi.org/10.1177/0272989X19855951DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6791732PMC
August 2019