Literature Collection

OBJECTIVE: Medication for opioid use disorder (MOUD) improves treatment retention and reduces illicit opioid use. A-CHESS is an evidence-based smartphone intervention shown to improve addiction-related behaviors. The authors tested the efficacy of MOUD alone versus MOUD plus A-CHESS to determine whether the combination further improved outcomes. METHODS: In an unblinded parallel-group randomized controlled trial, 414 participants recruited from outpatient programs were assigned in a 1:1 ratio to receive either MOUD alone or MOUD+A-CHESS for 16 months and were followed for an additional 8 months. All participants were on methadone, buprenorphine, or injectable naltrexone. The primary outcome was abstinence from illicit opioid use; secondary outcomes were treatment retention, health services use, other substance use, and quality of life; moderators were MOUD type, gender, withdrawal symptom severity, pain severity, and loneliness. Data sources were surveys comprising multiple validated scales, as well as urine screens, every 4 months. RESULTS: There was no difference in abstinence between participants in the MOUD+A-CHESS and MOUD-alone arms across time (odds ratio=1.10, 95% CI=0.90-1.33). However, abstinence was moderated by withdrawal symptom severity (odds ratio=0.95, 95% CI=0.91-1.00) and MOUD type (odds ratio=0.57, 95% CI=0.34-0.97). Among participants without withdrawal symptoms, abstinence rates were higher over time for those in the MOUD+A-CHESS arm than for those in the MOUD-alone arm (odds ratio=1.30, 95% CI=1.01-1.67). Among participants taking methadone, those in the MOUD+A-CHESS arm were more likely to be abstinent over time (b=0.28, SE=0.09) than those in the MOUD-alone arm (b=0.06, SE=0.08), although the two groups did not differ significantly from each other (∆b=0.22, SE=0.11). MOUD+A-CHESS was also associated with greater meeting attendance (odds ratio=1.25, 95% CI=1.05-1.49) and decreased emergency department and urgent care use (odds ratio=0.88, 95% CI=0.78-0.99). CONCLUSIONS: Overall, MOUD+A-CHESS did not improve abstinence relative to MOUD alone. However, MOUD+A-CHESS may provide benefits for subsets of patients and may impact treatment utilization.

BACKGROUND: In the context of escalating diabetes prevalence worldwide, this study investigates the efficacy of integrating cognitive behavioral therapy (CBT) within primary care visits for managing uncontrolled diabetes. DESIGN: The randomized clinical trial in an integrated health care clinic in Oregon involved 72 adults aged 20-89 with uncontrolled diabetes. Participants were enrolled and randomly assigned to 2 groups: one receiving both cognitive behavioral health (n=36) and the other receiving traditional primary care (n=36). RESULTS: The study primarily measured clinical improvements in hemoglobin A1C levels for a year. Results indicated significant improvements in the cognitive behavioral health group compared with the traditional care group at various intervals up to 51 weeks, with notable enhancements in hemoglobin A1C and secondary outcomes of patient satisfaction scores. During the 36th and 51st weeks, the shared visit group demonstrated significantly lower hemoglobin A1c levels (36 wk: 9.22±0.2 vs. 10.02±0.2, P<0.001; 51 wk: 9.22±0.1 vs. 10.91±0.2, P<0.001), indicating improved long-term glycemic control. CONCLUSIONS: Combining cognitive behavioral health with primary care visits significantly outperformed traditional care in improving clinical outcomes and patient satisfaction among adults with uncontrolled diabetes. The percentage of participants with clinically meaningful improvement in 36 weeks was 22.2% in the CBT versus 0.0% in the traditional primary care visit group. The positive outcomes suggest that integrated cognitive behavioral therapy can effectively contribute to diabetes management strategies, highlighting the importance of innovative approaches in addressing the diabetes epidemic.

This study evaluates the impact of a 6-month care management intervention for 206 children diagnosed with comorbid attention deficit hyperactivity disorder (ADHD) from a sample of 321 five- to 12-year-old children recruited for treatment of behavior problems in 8 pediatric primary care offices. Practices were cluster-randomized to Doctor Office Collaboration Care (DOCC) or Enhanced Usual Care (EUC). Chart reviews documented higher rates of service delivery, prescription of medication for ADHD, and titration in DOCC (vs EUC). Based on complex conditional models, DOCC showed greater acute improvement in individualized ADHD treatment goals and follow-up improvements in quality of life and ADHD and oppositional defiant disorder goals. Medication use had a significant effect on acute and follow-up ADHD symptom reduction and quality of life. Medication continuity was associated with some long-term gains. A collaborative care intervention for behavior problems that incorporated treatment guidelines for ADHD in primary care was more effective than psychoeducation and facilitated referral to community treatment.

Medicare and Medicaid are separate programs that together cover 13 million low-income older adults and people with disabilities, known as dual-eligible individuals. Concern about a lack of coordination across Medicare and Medicaid has prompted the development of Integrated Care Programs (ICPs). Although the primary goal of ICPs is to coordinate financing and care across Medicare and Medicaid, ICPs may also influence whether low-income individuals obtain or keep Medicaid. We evaluated whether the rollout of Medicare-Medicaid Plans (MMPs)-one of the largest ICPs-was associated with changes in Medicaid take-up and retention among Medicare beneficiaries residing in high-poverty zip codes. Using a stacked difference-in-differences design and variation in MMP rollouts across nine states, we found no evidence that MMPs increased monthly or continuous Medicaid enrollment in this population. These findings highlight the need for focused policies to address Medicaid enrollment gaps among low-income Medicare beneficiaries, which could complement broader integration efforts.

BACKGROUND: Depressive symptoms frequently co-occur with diabetes and, when unaddressed, can function to worsen diabetes control and increase the risk of diabetes-related morbidity. Integrated care (IC) approaches aim to improve outcomes among people with diabetes and depression, but there are no current meta-analyses examining their effects. PURPOSE: In our study we summarize the effects of IC approaches to address depression and diabetes and examine moderating effects of IC approaches (e.g., behavioral intervention used; type of IC approach). DATA SOURCES: A systematic search was conducted of PubMed, PsycInfo, CINAHL, and ProQuest. STUDY SELECTION: Two reviewers triaged abstracts and full-text articles to identify relevant articles. Randomized controlled trials with enrollment of participants with diabetes and depressive symptoms and with provision of sufficient data on depression scores and hemoglobin A1c were included. DATA EXTRACTION: Two reviewers extracted demographic information, depression scores, diabetes outcomes, intervention details, and the risk of bias for each study. DATA SYNTHESIS: From 517 abstracts, 75 full-text reports were reviewed and 31 studies with 8,843 participants were analyzed. Among 26 studies with reporting of HbA1c, IC approaches were associated with a significant between-group difference regarding the percent decrease of HbA1c (d = -0.36, 95% CI -0.52 to -0.21). Studies that included a combination of behavioral interventions (behavioral activation with cognitive behavioral therapy) showed greater reductions in HbA1c. Among 23 studies with reporting of depressive symptoms, the pooled effect of IC approaches lowered depressive scores by 0.72 points (95% CI -1.15 to -0.28). LIMITATIONS: The inclusion of a wide range of IC approaches increased study heterogeneity. A random effects model and sensitivity analyses mitigated this limitation. CONCLUSIONS: IC approaches are associated with improved glycemia and depressive symptoms in comparison with treatment as usual.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a leading global health burden, with high prevalence of comorbidities (e.g., hypertension and diabetes) that further increase healthcare utilization and mortality. Integrated care is proposed as a potential management strategy for COPD patients with comorbidities, but its overall effects remain unclear due to inconsistent evidence from prior studies. OBJECTIVES: To systematically evaluate the effects of integrated care on key health outcomes in patients with COPD and at least one comorbidity. DESIGN: Systematic review and meta-analysis. DATA SOURCES AND METHODS: Databases including MEDLINE, EMBASE, CENTRAL, CINAHL, and ClinicalTrial.gov were searched. Eligible studies were randomized controlled trials (RCTs) evaluating integrated care in patients with COPD and comorbidities. Two independent reviewers conducted study screening, data extraction, and quality assessment. Effects of integrated care were assessed using a random-effects model. RESULTS: Seven RCTs from high-income countries were included. Common integrated care components were health education, self-management support, and (in two studies) telemonitoring. Meta-analysis showed that integrated care significantly reduced the number of COPD exacerbations and all-cause hospitalizations. No significant effects were observed for all-cause emergency visits or CAT scores. CONCLUSION: Integrated care effectively reduces COPD exacerbations and all-cause hospitalizations in patients with COPD and comorbidities, supporting its clinical value. However, high heterogeneity across studies, limited generalizability to non-high-income countries (e.g., China), and lack of impact on patient-reported outcomes (CAT scores) highlight the need for further localized research. TRIAL REGISTRATION: Registered with PROSPERO, Registration ID: CRD420251170533.; COPD and comorbidities: the effects of integrated careChronic obstructive pulmonary disease (COPD), a serious lung condition affecting millions worldwide, often occurs alongside other health problems (e.g., heart disease, diabetes). These additional conditions can worsen outcomes, increasing hospital stays and even death. While “integrated care” (combining treatments, education, and long-term support) is often recommended for such patients, its benefits need clearer evidence. This study reviewed seven high-quality clinical trials from wealthier countries to evaluate how integrated care affects COPD patients with other health issues. Most programs included education, self-management training, and remote health monitoring. Key findings: Integrated care reduced sudden worsening of COPD symptoms (“exacerbations”). It also lowered the chance of being hospitalized for any health reason. However, it did not significantly reduce emergency room visits or improve patients’ self-reported symptom scores (CAT scores). These results suggest that integrated care can help stabilize COPD patients and reduce hospital stays, making it a valuable approach for healthcare systems. However, more research is needed to adapt these programs for low-income regions and to improve their impact on quality of life.; eng