Literature Collection

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

PURPOSE: A pragmatic, cluster-randomized controlled trial of a comprehensive practice-level, multi-staged practice transformation intervention aimed to increase behavioral health integration in primary care practices and improve patient outcomes. We examined association between the completion of intervention stages and patient outcomes across a heterogenous national sample of primary care practices. METHODS: Forty-two primary care practices across the U.S. with co-located behavioral health and 2,426 patients with multiple chronic medical and behavioral health conditions completed surveys at baseline, midpoint and two year follow-up. Effects of the intervention on patient health and primary care integration outcomes were examined using multilevel mixed-effects models, while controlling for baseline outcome measurements. RESULTS: No differences were found associated with the number of intervention stages completed in patient health outcomes were found for depression, anxiety, fatigue, sleep disturbance, pain, pain interference, social function, patient satisfaction with care or medication adherence. The completion of each intervention stage was associated with increases in Practice Integration Profile (PIP) domain scores and were confirmed with modeling using multiple imputation for: Workflow 3.5 (95% CI: 0.9-6.1), Integration Methods 4.6 (95% CI: 1.5-7.6), Patient Identification 2.9 (95% CI: 0.9-5.0), and Total Integration 2.7 (95% CI: 0.7-4.7). CONCLUSION: A practice-centric flexible practice transformation intervention improved integration of behavioral health in primary care across heterogenous primary care practices treating patients with multiple chronic conditions. Interventions that allow practices to flexibly improve care have potential to help complex patient populations. Future research is needed to determine how to best target patient health outcomes at a population level.

BACKGROUND: Office-based opioid treatment with buprenorphine has emerged as a popular evidence-based treatment for opioid use disorder. Unfortunately, psychosocial stress, anxiety, pain, and co-morbid substance use increase patients' risk for relapse. We designed this study to compare the effects of complementing buprenorphine treatment with 24 weeks of a live-online Mindful Recovery Opioid Care Continuum (M-ROCC) group to a time and attention-matched, live-online Recovery Support Group (RSG) active control condition. METHODS: We plan to enroll a maximum of N = 280 and randomize at least N = 192 patients prescribed buprenorphine through referrals from office-based and telemedicine buprenorphine treatment providers and social media advertisements. Participants will be randomly assigned to M-ROCC or RSG and will be blinded to their treatment condition. The primary outcome for this study will be biochemically confirmed periods of abstinence from illicit opioids, as measured by self-reported use and randomly collected, video-observed oral fluid toxicology testing during the final 12 weeks of study participation. Secondary outcomes include changes in Patient-Reported Outcomes Measurement Information System (PROMIS) anxiety and pain interference scores between baseline and week 24. RESULTS: The trial was funded by the National Institutes of Health, HEAL Initiative through NCCIH (R33AT010125). Data collection is projected to end by September 2023, and we expect publication of results in 2024. CONCLUSION: If the M-ROCC intervention is found to be effective in this format, it will demonstrate that live-online mindfulness groups can improve outcomes and address common co-morbidities like anxiety and pain during buprenorphine treatment.