Controller Medications and Serious Early Childhood Lower Respiratory Tract Illnesses

Posted on May 7, 2021May 18, 2021 by coprhcon

BACKGROUND

While asthma controllers (inhaled corticosteroids and leukotriene inhibitors) have been shown to reduce exacerbations in children 2-5 years old with asthma or recurrent wheeze, deciding when to prescribe controllers in children <2 years old remains challenging given the substantial clinical overlap between asthma and lower respiratory tract infections (LRTIs). Our objective was to assess the association between time on controller medications and emergency department (ED) and inpatient (IP) visits for LRTI or asthma in children <2 years old.

METHODS

Retrospective cohort study using administrative claims data. The primary exposure variable was a time-dependent indicator for presence of a prescription for controller medication. The primary outcome was count of ED/IP visits for any diagnosis of LRTI or ED/IP visit for a primary diagnosis of asthma after the first LRTI (using ICD9/10 codes). A Poisson regression model accounting for correlation within subjects was used. Adjusted models included baseline covariates for gender, insurance type, prematurity, family history of asthma claim, and time-dependent covariates of prior wheeze claim, atopy claim, number of LRTI visits, LRTI hospitalizations, prior subspecialty claim (Allergy/Immunology or Pulmonology), and outpatient beta agonist prescriptions.

RESULTS

We identified 40,473 children meeting inclusion criteria, ultimately constituting 547,082 person-months. A larger percentage of person-time on controller compared to off controller was seen with older age, male gender, Medicaid insurance, family history of asthma claim, prior atopy claim, prior wheeze claim, more prior LRTI visits, and prior outpatient beta agonist prescription. Controller medication use was not significantly associated with a reduction in ED/IP visits for LRTI or asthma in the adjusted model (RR 0.77; 95% CI: 0.57, 1.05).

The Substance Abuse Treatment to HIV Care (SAT2HIV) Project: An example of a completed dual-randomized type 2 hybrid trial

Posted on May 7, 2021May 18, 2021 by coprhcon

BACKGROUND

To help “speed the translation of research findings into routine practice” Curran and colleagues (2012) codified three types of hybrid trial designs (i.e., Type 1, Type 2, and Type 3). As part of type 2 hybrid trials they proposed “dual testing of clinical and implementation interventions/strategies.” Despite their note about using the term test in a “liberal manner” (i.e., the clinical and implementation interventions/strategies need not all be tested with randomized, strongly powered designs), in 2014 the National Institute on Drug Abuse funded a dual-randomized type 2 implementation-effectiveness hybrid trial called the Substance Abuse Treatment to HIV care (SAT2HIV) Project. Consistent with theme area 1 (Pragmatic Trial Examples), this presentation/poster will provide a concrete example of what Landes, McBain, and Curran (2019) highlighted as a “rarer” type 2 hybrid trial example.

METHODS

A dual-randomized type 2 implementation-effectiveness hybrid trial, which simultaneously included: 1) a 39-site cluster-randomized implementation trial focused on testing the effectiveness of the team-focused Implementation & Sustainment Facilitation (ISF) Strategy as an adjunct to the staff-focused Addiction Technology Transfer Center.

(ATTC) Strategy, and 2) a multisite randomized controlled trial testing the effectiveness of a motivational interviewing-based brief intervention for substance use as an adjunct to HIV service organization’s usual care for substance use disorders. Both staff-level outcomes and client-level outcomes were examined.

RESULTS

The ISF Strategy had a significant impact on implementation effectiveness (i.e., the consistency and the quality of implementation; ? = .65, p = .01), but not on time-to-proficiency (? = ?.02), or level-of-sustainment (? = .09). Additionally, the ISF Strategy had a significant impact on intervention effectiveness (i.e., the effectiveness of the MIBI), at least in terms of significantly decreasing the odds (odds ratio = 0.11, p = .02) of clients using their primary substance daily during follow-up.

Implementation and Evaluation of the Exercise is Medicine Program in Primary Care

Posted on May 7, 2021May 18, 2021 by coprhcon

BACKGROUND

Insufficient physical activity (PA) is a leading risk factor for most chronic health conditions. Identifying patients at higher risk of these conditions due to their insufficient levels of PA is one of the highest priorities given the evidence suggesting that insufficient PA poses as much of a risk to patients’ health as other established risk factors that are routinely addressed within the primary care setting (e.g., smoking, hypertension, obesity) and creates a significant financial burden on the healthcare system. Numerous interventions effectively increase PA, but few are integrated into primary care clinic workflows. Exercise is Medicine (EIM) is a global health initiative committed to the belief that PA is integral to the prevention and treatment of diseases and should be routinely assessed as a vital sign and treated in the healthcare setting.

METHODS

The Practical, Robust Implementation and Sustainability Model (PRISM) guided pre-implementation evaluation and adaptation of EIM protocol, materials, and delivery strategies. The Learning Evaluation QI model is used to design, test, refine, and implement EIM using rapid, 3-month Plan Do Study Act micro-cycles. The Stirman Framework is used to document adaptations to the program throughout implementation. Reach, adoption, implementation, effectiveness, and maintenance (RE-AIM) outcomes embedded within PRISM are used to guide the program evaluation to determine sustainability and scalability. Data is obtained through the electronic medical record (EMR) and periodic patient surveys.

RESULTS

In terms of adoption and reach, a total of 38,899 PAVS (Physical Activity Vital Sign) self-reported questionnaires have been recorded in the EMR, representing a total of 17,275 unique patients, which translated to 35%, 43%, 82, and 87% of all patients seen in each of the four clinics (integrated on a rolling basis). Implementation of the different program components (screening, diagnosis, PCP discussion, documentation, prescription, and optional health coaching) has been high with the exception of documentation. Patients recalled discussing PA with their PCPs and/or receiving information about exercise in 73% of visits. Effectiveness and maintenance will be evaluated in the next 3 years. Discussion: Using an innovative approach of combining IS and QI methods to improve the identification of primary care patients with insufficient PA to increase their activity levels has great population health potential. Our work will inform best approaches for EIM integration in primary care.