Literature Collection

IMPORTANCE: Addiction treatment rapidly transitioned to a primarily telehealth modality (telephone and video) during the COVID-19 pandemic, raising concerns about disparities in utilization. OBJECTIVE: To examine whether there were differences in overall and telehealth addiction treatment utilization after telehealth policy changes during the COVID-19 pandemic by age, race, ethnicity, and socioeconomic status. DESIGN, SETTING, AND PARTICIPANTS: This cohort study examined electronic health record and claims data from Kaiser Permanente Northern California for adults (age ≥18 years) with drug use problems before the COVID-19 pandemic (from March 1, 2019, to December 31, 2019) and during the early phase of the COVID-19 pandemic (March 1, 2020, to December 31, 2020; hereafter referred to as COVID-19 onset). Analyses were conducted between March 2021 and March 2023. EXPOSURE: The expansion of telehealth services during COVID-19 onset. MAIN OUTCOMES AND MEASURES: Generalized estimating equation models were fit to compare addiction treatment utilization during COVID-19 onset with that before the COVID-19 pandemic. Utilization measures included the Healthcare Effectiveness Data and Information Set of treatment initiation and engagement (including inpatient, outpatient, and telehealth encounters or receipt of medication for opioid use disorder [OUD]), 12-week retention (days in treatment), and OUD pharmacotherapy retention. Telehealth treatment initiation and engagement were also examined. Differences in changes in utilization by age group, race, ethnicity, and socioeconomic status (SES) were examined. RESULTS: Among the 19 648 participants in the pre-COVID-19 cohort (58.5% male; mean [SD] age, 41.0 [17.5] years), 1.6% were American Indian or Alaska Native; 7.5%, Asian or Pacific Islander; 14.3%, Black; 20.8%, Latino or Hispanic; 53.4%, White; and 2.5%, unknown race. Among the 16 959 participants in the COVID-19 onset cohort (56.5% male; mean [SD] age, 38.9 [16.3] years), 1.6% were American Indian or Alaska Native; 7.4%, Asian or Pacific Islander; 14.6%, Black; 22.2%, Latino or Hispanic; 51.0%, White; and 3.2%, unknown race. Odds of overall treatment initiation increased from before the COVID-19 pandemic to COVID-19 onset for all age, race, ethnicity, and SES subgroups except for patients aged 50 years or older; patients aged 18 to 34 years had the greatest increases (adjusted odds ratio [aOR], 1.31; 95% CI, 1.22-1.40). Odds of telehealth treatment initiation increased for all patient subgroups without variation by race, ethnicity, or SES, although increases were greater for patients aged 18 to 34 years (aOR, 7.17; 95% CI, 6.24-8.24). Odds of overall treatment engagement increased (aOR, 1.13; 95% CI, 1.03-1.24) without variation by patient subgroups. Retention increased by 1.4 days (95% CI, 0.6-2.2 days), and OUD pharmacotherapy retention did not change (adjusted mean difference, -5.2 days; 95% CI, -12.7 to 2.4 days). CONCLUSIONS: In this cohort study of insured adults with drug use problems, there were increases in overall and telehealth addiction treatment utilization after telehealth policies changed during the COVID-19 pandemic. There was no evidence that disparities were exacerbated, and younger adults may have particularly benefited from the transition to telehealth.

CONTEXT: The United States is in the midst of an opioid overdose epidemic. Opioids killed more than 28 000 people in 2014, more than any year on record. One approach to addressing this growing epidemic is Opioid Overdose Education and Naloxone Distribution (OEND) training. Little is known about these programs' participants and their effectiveness across different demographic groups. OBJECTIVES: To examine (1) whether knowledge and attitudes improved over the course of the training programs; (2) whether training outcomes differ by demographics; and (3) what overdose experiences do attendees have, and whether those experiences influence their knowledge and attitudes. DESIGN: A pre- and posttest survey was used to collect data on participants' demographics, overdose experiences, and opioid overdose knowledge and attitudes. SETTING: Surveys that took place at community-wide OEND programs were offered throughout Erie County, New York, during October and November 2015. PARTICIPANTS: Community members who elected to attend the training programs, were at least 18 years of age, spoke English, and were willing and able to participate were included in the sample (N = 198). INTERVENTION: N/A. MAIN OUTCOME MEASURE: The Opioid Overdose Knowledge and Attitudes Scale. RESULTS: Knowledge and attitude scores significantly improved from pre- to posttest assessments, increasing by 23.1% and 15.4%, respectively (Ps < .001). There were significant demographic differences in knowledge and attitudes at the pretest assessment, but these differences were ameliorated by the OEND program and did not persist at posttest assessment. In addition, 62.9% of participants had never experienced, witnessed, or known someone who had overdosed. CONCLUSION: Results indicate that OEND programs are effective at improving knowledge and attitudes toward opioid overdose. These results indicate that OEND programs are not reaching the highest risk individuals but are instead attracting concerned family and significant others. Future programs should focus on reaching current opioid users, overdose victims, and their families to ensure OEND programs are reaching the target audiences.

IMPORTANCE: Care management benefits community-dwelling patients with dementia, but studies include few patients with moderate to severe dementia or from racial and ethnic minority populations, lack palliative care, and seldom reduce health care utilization. OBJECTIVE: To determine whether integrated dementia palliative care reduces dementia symptoms, caregiver depression and distress, and emergency department (ED) visits and hospitalizations compared with usual care in moderate to severe dementia. DESIGN, SETTING, AND PARTICIPANTS: A randomized clinical trial of community-dwelling patients with moderate to severe dementia and their caregivers enrolled from March 2019 to December 2020 from 2 sites in central Indiana (2-year follow-up completed on January 7, 2023). Electronic health record screening identified patients with dementia; caregivers confirmed eligibility, including dementia stage. INTERVENTION: The intervention consisted of monthly calls from a trained nurse or social worker and evidence-based protocols to help caregivers manage patients' neuropsychiatric symptoms, caregiver distress, and palliative care issues (eg, advance care planning, symptoms, and hospice) (n = 99). Usual care caregivers received written dementia resource information and patients received care from usual clinicians (n = 102). MAIN OUTCOMES AND MEASURES: The primary outcome was Neuropsychiatric Inventory Questionnaire (NPI-Q) severity score (scores range from 0-36, with higher scores indicating worse patient symptoms). Secondary outcomes included Symptom Management in End-of-Life Dementia scores, caregiver depression (Patient Health Questionnaire-8) scores, caregiver distress (NPI-Q distress) scores, and combined ED and hospitalization events. Outcomes were assessed quarterly for 24 months or until patient death. RESULTS: A total of 201 dyads were enrolled (patients were 67.7% female; 43.3% African American; mean [SD] age, 83.6 [7.9] years); 3 dyads withdrew and 83 patients died over the course of the study, with at least 90% of eligible dyads in both groups completing each of the quarterly assessments. For the dementia palliative care vs usual care groups, mean NPI-Q severity scores were 9.92 vs 9.41 at baseline and 9.15 vs 9.39 at 24 months, respectively (between-group difference at 24 months, -0.24 [95% CI, -2.33 to 1.84]). There was no significant difference in the rate of change in NPI-Q severity from baseline between groups over time (P = .87 for the group and time interaction). There were no significant differences in the secondary outcomes, except that there were fewer combined ED and hospitalization events in the dementia palliative care group (mean events/patient, 1.06 in dementia palliative care vs 2.37 in usual care; between-group difference, -1.31 [95% CI, -1.93 to -0.69]; relative risk, 0.45 [95% CI, 0.31 to 0.65]). CONCLUSIONS AND RELEVANCE: Among community-dwelling patients with moderate to severe dementia and their caregivers, dementia palliative care, compared with usual care, did not significantly improve patients' neuropsychiatric symptoms through 24 months. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03773757.

In order to investigate the patient experience of integrated behavioral health care in primary care settings, we implemented a patient cohort model from a combined site sample (N = 727) consisting of a family practice clinic and a Federally Qualified Health Center. Patient experience was measured using 12 questions from a validated measure, the Agency for Healthcare Research and Quality's Consumer Assessment of Health Care Providers and Systems (CAHPS®), Home and Community Based Services version, and six additional questions about interactions with an integrated behavioral health care team. We assessed bivariate relationships between satisfaction with integration and the clinic practice and self-reported physical health or self-reported mental/emotional health. We also utilized multiple regression to evaluate this relationship. Our analyses showed a statistically significant and small to moderate direct correlation between patients' self-reported health (both physical and mental/emotional health) and their ratings of the practice as a whole (p = .0003), such that patients who rated their physical and/or mental/emotional health as better were more likely to rate their overall satisfaction with the practice higher. The results of this study suggest that primary care patients with only mild to moderate health conditions (physical and/or mental/emotional) may experience greater satisfaction with integrated behavioral health care than patients with multiple and/or severe health conditions. In contrast, patients with multiple and/or severe health conditions may experience lower satisfaction with integrated behavioral health care and may be better served through higher levels of care.

BACKGROUND: Guidelines on the management of depression recommend that practitioners use patient-reported outcome measures for the follow-up monitoring of symptoms, but there is a lack of evidence of benefit in terms of patient outcomes. OBJECTIVE: To test using the Patient Health Questionnaire-9 questionnaire as a patient-reported outcome measure for monitoring depression, training practitioners in interpreting scores and giving patients feedback. DESIGN: Parallel-group, cluster-randomised superiority trial; 1 : 1 allocation to intervention and control. SETTING: UK primary care (141 group general practices in England and Wales). INCLUSION CRITERIA: Patients aged ≥ 18 years with a new episode of depressive disorder or symptoms, recruited mainly through medical record searches, plus opportunistically in consultations. EXCLUSIONS: Current depression treatment, dementia, psychosis, substance misuse and risk of suicide. INTERVENTION: Administration of the Patient Health Questionnaire-9 questionnaire with patient feedback soon after diagnosis, and at follow-up 10-35 days later, compared with usual care. PRIMARY OUTCOME: Beck Depression Inventory, 2nd edition, symptom scores at 12 weeks. SECONDARY OUTCOMES: Beck Depression Inventory, 2nd edition, scores at 26 weeks; antidepressant drug treatment and mental health service contacts; social functioning (Work and Social Adjustment Scale) and quality of life (EuroQol 5-Dimension, five-level) at 12 and 26 weeks; service use over 26 weeks to calculate NHS costs; patient satisfaction at 26 weeks (Medical Informant Satisfaction Scale); and adverse events. SAMPLE SIZE: The original target sample of 676 patients recruited was reduced to 554 due to finding a significant correlation between baseline and follow-up values for the primary outcome measure. RANDOMISATION: Remote computerised randomisation with minimisation by recruiting university, small/large practice and urban/rural location. BLINDING: Blinding of participants was impossible given the open cluster design, but self-report outcome measures prevented observer bias. Analysis was blind to allocation. ANALYSIS: Linear mixed models were used, adjusted for baseline depression, baseline anxiety, sociodemographic factors, and clustering including practice as random effect. Quality of life and costs were analysed over 26 weeks. QUALITATIVE INTERVIEWS: Practitioner and patient interviews were conducted to reflect on trial processes and use of the Patient Health Questionnaire-9 using the Normalization Process Theory framework. RESULTS: Three hundred and two patients were recruited in intervention arm practices and 227 patients were recruited in control practices. Primary outcome data were collected for 252 (83.4%) and 195 (85.9%), respectively. No significant difference in Beck Depression Inventory, 2nd edition, score was found at 12 weeks (adjusted mean difference -0.46, 95% confidence interval -2.16 to 1.26). Nor were significant differences found in Beck Depression Inventory, 2nd Edition, score at 26 weeks, social functioning, patient satisfaction or adverse events. EuroQol-5 Dimensions, five-level version, quality-of-life scores favoured the intervention arm at 26 weeks (adjusted mean difference 0.053, 95% confidence interval 0.013 to 0.093). However, quality-adjusted life-years over 26 weeks were not significantly greater (difference 0.0013, 95% confidence interval -0.0157 to 0.0182). Costs were lower in the intervention arm but, again, not significantly (-£163, 95% confidence interval -£349 to £28). Cost-effectiveness and cost-utility analyses, therefore, suggested that the intervention was dominant over usual care, but with considerable uncertainty around the point estimates. Patients valued using the Patient Health Questionnaire-9 to compare scores at baseline and follow-up, whereas practitioner views were more mixed, with some considering it too time-consuming. CONCLUSIONS: We found no evidence of improved depression management or outcome at 12 weeks from using the Patient Health Questionnaire-9, but patients' quality of life was better at 26 weeks, perhaps because feedback of Patient Health Questionnaire-9 scores increased their awareness of improvement in their depression and reduced their anxiety. Further research in primary care should evaluate patient-reported outcome measures including anxiety symptoms, administered remotely, with algorithms delivering clear recommendations for changes in treatment. STUDY REGISTRATION: This study is registered as IRAS250225 and ISRCTN17299295. FUNDING: This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 17/42/02) and is published in full in Health Technology Assessment; Vol. 28, No. 17. See the NIHR Funding and Awards website for further award information.; Depression is common, can be disabling and costs the nation billions. The National Health Service recommends general practitioners who treat people with depression use symptom questionnaires to help assess whether those people are getting better over time. A symptom questionnaire is one type of patient-reported outcome measure. Patient-reported outcome measures appear to benefit people having therapy and mental health care, but this approach has not been tested thoroughly in general practice. Most people with depression are treated in general practice, so it is important to test patient-reported outcome measures there, too. In this study, we tested whether using a patient-reported outcome measure helps people with depression get better more quickly. The study was a ‘randomised controlled trial’ in general practices, split into two groups. In one group, people with depression completed the Patient Health Questionnaire, or ‘PHQ-9’, patient-reported outcome measure, which measures nine symptoms of depression. In the other group, people with depression were treated as usual without the Patient Health Questionnaire-9. We fed the results of the Patient Health Questionnaire-9 back to the people with depression themselves to show them how severe their depression was and asked them to discuss the results with the practitioners looking after them. We found no differences between the patient-reported outcome measure group and the control group in their level of depression; their work or social life; their satisfaction with care from their practice; or their use of medicines, therapy or specialist care for depression. However, we did find that their quality of life was improved at 6 months, and the costs of the National Health Service services they used were lower. Using the Patient Health Questionnaire-9 can improve patients’ quality of life, perhaps by making them more aware of improvement in their depression symptoms, and less anxious as a result. Future research should test using a patient-reported outcome measure that includes anxiety and processing the answers through a computer to give practitioners clearer advice on possible changes to treatment for depression.; eng

Effective care integration requires the right information, at the right time, with care and support delivered in the right environment. Patient-reported outcome measures [PROMs] offer a mechanism to support collaborative integrated care to help people understand their conditions better, live well, and remain independent. Through the lens of the delivery of integrated care in England, we consider the opportunities and challenges associated with the use of PROMs across health and care.