P. M. Ann M. Nguyen, PhD Charles M. Cleland, PhD L. Miriam Dickinson, Michael P. Barry, MD Samuel Cykert, M. M. F. Daniel Duffy, M. M. Anton J. Kuzel, PhD Stephan R. Lindner, M. M. Michael L. Parchman, M. M. Donna R. Shelley, PhD Theresa L. Walunas
PURPOSE Despite the growing popularity of stepped-wedge cluster randomized trials (SW-CRTs) for practice-based research, the design’s advantages and challenges are not well documented. The objective of this study was to identify the advantages and challenges of the SW-CRT design for large-scale intervention implementations in primary care settings. METHODS The EvidenceNOW: Advancing Heart Health initiative, funded by the Agency for Healthcare Research and Quality, included a large collection of SW-CRTs. We conducted qualitative interviews with 17 key informants from EvidenceNOW grantees to identify the advantages and challenges of using SW-CRT design. RESULTS All interviewees reported that SW-CRT can be an effective study design for large-scale intervention implementations. Advantages included (1) incentivized recruitment, (2) staggered resource allocation, and (3) statistical power. Challenges included (1) time-sensitive recruitment, (2) retention, (3) randomization requirements and practice preferences, (4) achieving treatment schedule fidelity, (5) intensive data collection, (6) the Hawthorne effect, and (7) temporal trends. CONCLUSIONS The challenges experienced by EvidenceNOW grantees suggest that certain favorable real-world conditions constitute a context that increases the odds of a successful SW-CRT. An existing infrastructure can support the recruitment of many practices. Strong retention plans are needed to continue to engage sites waiting to start the intervention. Finally, study outcomes should be ones already captured in routine practice; otherwise, funders and investigators should assess the feasibility and cost of data collection. VISUAL ABSTRACT
{"title":"Considerations Before Selecting a Stepped-Wedge Cluster Randomized Trial Design for a Practice Improvement Study","authors":"P. M. Ann M. Nguyen, PhD Charles M. Cleland, PhD L. Miriam Dickinson, Michael P. Barry, MD Samuel Cykert, M. M. F. Daniel Duffy, M. M. Anton J. Kuzel, PhD Stephan R. Lindner, M. M. Michael L. Parchman, M. M. Donna R. Shelley, PhD Theresa L. Walunas","doi":"10.1370/afm.2810","DOIUrl":"https://doi.org/10.1370/afm.2810","url":null,"abstract":"PURPOSE Despite the growing popularity of stepped-wedge cluster randomized trials (SW-CRTs) for practice-based research, the design’s advantages and challenges are not well documented. The objective of this study was to identify the advantages and challenges of the SW-CRT design for large-scale intervention implementations in primary care settings. METHODS The EvidenceNOW: Advancing Heart Health initiative, funded by the Agency for Healthcare Research and Quality, included a large collection of SW-CRTs. We conducted qualitative interviews with 17 key informants from EvidenceNOW grantees to identify the advantages and challenges of using SW-CRT design. RESULTS All interviewees reported that SW-CRT can be an effective study design for large-scale intervention implementations. Advantages included (1) incentivized recruitment, (2) staggered resource allocation, and (3) statistical power. Challenges included (1) time-sensitive recruitment, (2) retention, (3) randomization requirements and practice preferences, (4) achieving treatment schedule fidelity, (5) intensive data collection, (6) the Hawthorne effect, and (7) temporal trends. CONCLUSIONS The challenges experienced by EvidenceNOW grantees suggest that certain favorable real-world conditions constitute a context that increases the odds of a successful SW-CRT. An existing infrastructure can support the recruitment of many practices. Strong retention plans are needed to continue to engage sites waiting to start the intervention. Finally, study outcomes should be ones already captured in routine practice; otherwise, funders and investigators should assess the feasibility and cost of data collection. VISUAL ABSTRACT","PeriodicalId":22305,"journal":{"name":"The Annals of Family Medicine","volume":"35 1","pages":"255 - 261"},"PeriodicalIF":0.0,"publicationDate":"2022-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"73825082","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"DEPARTMENTS OF FAMILY MEDICINE MEETING POST-COVID NEEDS","authors":"K. Narasimhan, Richard Lord","doi":"10.1370/afm.2834","DOIUrl":"https://doi.org/10.1370/afm.2834","url":null,"abstract":"","PeriodicalId":22305,"journal":{"name":"The Annals of Family Medicine","volume":"42 1","pages":"290 - 291"},"PeriodicalIF":0.0,"publicationDate":"2022-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"88649271","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"BUILDING PRIORITIES IN HEALTH & HEALTH CARE INTO ABFM’S KNOWLEDGE ASSESSMENTS","authors":"W. Newton, Lara J. Handler, M. Magill","doi":"10.1370/afm.2840","DOIUrl":"https://doi.org/10.1370/afm.2840","url":null,"abstract":"","PeriodicalId":22305,"journal":{"name":"The Annals of Family Medicine","volume":"36 1 1","pages":"287 - 289"},"PeriodicalIF":0.0,"publicationDate":"2022-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"76014905","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Creating Avenues to Specialty Care—Could COVID-19 Force Change in the Way We Access Specialty Care?","authors":"Jessica Motley, M. Johansen","doi":"10.1370/afm.2836","DOIUrl":"https://doi.org/10.1370/afm.2836","url":null,"abstract":"","PeriodicalId":22305,"journal":{"name":"The Annals of Family Medicine","volume":"22 1","pages":"300 - 300"},"PeriodicalIF":0.0,"publicationDate":"2022-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"79071648","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
society, but has also reminded us anew of the limitations and challenges of our scientific approaches. Take the example of randomized trials. While multiple randomized trials were demonstrating the efficacy and safety of SARSCoV-2 vaccines,1 it became clear that other interventions against SARS-CoV-2 (eg, community masking, physical distancing, school closures, national lockdowns, etc) required research paradigms outside of the classic randomized trial design to which many scientists are accustomed.2,3 This again reminds us that randomized trials may have significant practical limitations to their generalizability because they are in tightly controlled settings with narrow eligibility, and therefore often in settings divorced from the real world.4 Whereas classic randomized trials evaluate interventions in ideal settings, pragmatic trials evaluate interventions against real-world alternatives provided in routine care (especially in primary care). Typically, pragmatic trials also relax eligibility criteria which may allow for greater generalizability of study findings. With the benefit of generalizability, however, comes challenges that are unique to pragmatic trials. To balance the relative risks and benefits of both of these designs, investigators employ strategies that often hybridize the 2 designs to maximize benefit and minimize limitation. In this issue, 3 studies demonstrate increasingly used approaches to construct trials that are pragmatic, but retain features and benefits of classic trial design. First, a randomized controlled trial led by Mitchell et al5 sought to evaluate the relative effectiveness of additions to a nationally disseminated readmission reduction program (called Re-Engineered Discharge [RED]) to reduce hospital readmission rates and emergency department visits among depressed patients. In intent-to-treat (ITT) analyses, the study found no difference in all-cause hospitalization between the study arms. Intent-to-treat analyses are used in trials to account for real-word deviation from treatment, and include all randomized study participants in prespecified analyses regardless of events after they are randomized (eg, noncompliance, study withdrawal, protocol deviation, etc). Intent-to-treat analyses are thought to produce less bias than when the randomized participants who were entirely adherent to their assigned intervention are included in this analysis.6 An alternative to an intent-to-treat analysis is to consider as-treated analyses which compares intervention groups that only include patients who actually received the treatment(s) without regard to their randomized assignment.6 In addition to intent-to-treat analyses, Mitchell et al5 also performed as-treated analyses and found that with sufficient uptake of the adapted RED intervention, patients saw a larger decrease in hospital readmission compared with RED alone. While it is tempting to consider the as-treated analysis a definitive analysis, it is known that as-tre
{"title":"Randomized Trials in Primary Care: Becoming Pragmatic","authors":"M. Marino, J. Heintzman","doi":"10.1370/afm.2832","DOIUrl":"https://doi.org/10.1370/afm.2832","url":null,"abstract":"society, but has also reminded us anew of the limitations and challenges of our scientific approaches. Take the example of randomized trials. While multiple randomized trials were demonstrating the efficacy and safety of SARSCoV-2 vaccines,1 it became clear that other interventions against SARS-CoV-2 (eg, community masking, physical distancing, school closures, national lockdowns, etc) required research paradigms outside of the classic randomized trial design to which many scientists are accustomed.2,3 This again reminds us that randomized trials may have significant practical limitations to their generalizability because they are in tightly controlled settings with narrow eligibility, and therefore often in settings divorced from the real world.4 Whereas classic randomized trials evaluate interventions in ideal settings, pragmatic trials evaluate interventions against real-world alternatives provided in routine care (especially in primary care). Typically, pragmatic trials also relax eligibility criteria which may allow for greater generalizability of study findings. With the benefit of generalizability, however, comes challenges that are unique to pragmatic trials. To balance the relative risks and benefits of both of these designs, investigators employ strategies that often hybridize the 2 designs to maximize benefit and minimize limitation. In this issue, 3 studies demonstrate increasingly used approaches to construct trials that are pragmatic, but retain features and benefits of classic trial design. First, a randomized controlled trial led by Mitchell et al5 sought to evaluate the relative effectiveness of additions to a nationally disseminated readmission reduction program (called Re-Engineered Discharge [RED]) to reduce hospital readmission rates and emergency department visits among depressed patients. In intent-to-treat (ITT) analyses, the study found no difference in all-cause hospitalization between the study arms. Intent-to-treat analyses are used in trials to account for real-word deviation from treatment, and include all randomized study participants in prespecified analyses regardless of events after they are randomized (eg, noncompliance, study withdrawal, protocol deviation, etc). Intent-to-treat analyses are thought to produce less bias than when the randomized participants who were entirely adherent to their assigned intervention are included in this analysis.6 An alternative to an intent-to-treat analysis is to consider as-treated analyses which compares intervention groups that only include patients who actually received the treatment(s) without regard to their randomized assignment.6 In addition to intent-to-treat analyses, Mitchell et al5 also performed as-treated analyses and found that with sufficient uptake of the adapted RED intervention, patients saw a larger decrease in hospital readmission compared with RED alone. While it is tempting to consider the as-treated analysis a definitive analysis, it is known that as-tre","PeriodicalId":22305,"journal":{"name":"The Annals of Family Medicine","volume":"550 1","pages":"201 - 202"},"PeriodicalIF":0.0,"publicationDate":"2022-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"88587169","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
When I was a new social worker, a series of events changed my clinical practice. I believed academic pursuits and scholarly work were the key components to cultivating my clinical skills. My education had elucidated the importance of taking the time to listen to the patient’s narrative to optimize their care. I recognized the value of listening and yet I was mystified and frustrated by my lack of success at building rapport with patients. I began my quest to find a mentor and discovered him in a most surprising place. I learned the best strategies to help people were not always found in books or taught in school. Some of the greatest gifts come from unexpected places.
{"title":"Gifts From Unexpected Places","authors":"Adrienne Feller Novick","doi":"10.1370/afm.2793","DOIUrl":"https://doi.org/10.1370/afm.2793","url":null,"abstract":"When I was a new social worker, a series of events changed my clinical practice. I believed academic pursuits and scholarly work were the key components to cultivating my clinical skills. My education had elucidated the importance of taking the time to listen to the patient’s narrative to optimize their care. I recognized the value of listening and yet I was mystified and frustrated by my lack of success at building rapport with patients. I began my quest to find a mentor and discovered him in a most surprising place. I learned the best strategies to help people were not always found in books or taught in school. Some of the greatest gifts come from unexpected places.","PeriodicalId":22305,"journal":{"name":"The Annals of Family Medicine","volume":"3 1","pages":"279 - 280"},"PeriodicalIF":0.0,"publicationDate":"2022-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"80692779","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
S. Davis, Leslee Roberts, J. Desborough, Sally Hall Dykgraaf, P. Burns, Michael Kidd, R. Maddox, Lucas de Toca, K. Lokuge
Integrating primary care with the health response is key to managing pandemics and other health emergencies. In recognition of this, the Australian Government established a network of respiratory clinics led by general practitioners in response to the coronavirus disease 2019 (COVID-19) pandemic as part of broader measures aimed at supporting primary care. General practitioner (GP) respiratory clinics provide holistic face-to-face assessment and treatment to those with respiratory symptoms in an environment with strict protocols for infection prevention and control. This ensures that these patients are able to access high quality primary care while protecting the general practice workforce and other patients. The GP respiratory clinic model was developed and operationalized 10 days after the policy was announced, with the first 2 respiratory clinics opening on March 21, 2020. Subsequently a total of 150 respiratory clinics were opened and served over 800,000 patients within more than 99% of Australia’s postcodes. These clinics used a standardized data collection tool that has provided the largest and most complete primary care surveillance database of respiratory illness in Australia. The success of the GP respiratory clinic model was made possible due to strong partnerships with Primary Health Networks and individual general practices that rapidly shifted operations to embrace this new approach. This article describes the development and early implementation of this model.
{"title":"Integrating General Practice Into the Australian COVID-19 Response: A Description of the General Practitioner Respiratory Clinic Program in Australia","authors":"S. Davis, Leslee Roberts, J. Desborough, Sally Hall Dykgraaf, P. Burns, Michael Kidd, R. Maddox, Lucas de Toca, K. Lokuge","doi":"10.1370/afm.2808","DOIUrl":"https://doi.org/10.1370/afm.2808","url":null,"abstract":"Integrating primary care with the health response is key to managing pandemics and other health emergencies. In recognition of this, the Australian Government established a network of respiratory clinics led by general practitioners in response to the coronavirus disease 2019 (COVID-19) pandemic as part of broader measures aimed at supporting primary care. General practitioner (GP) respiratory clinics provide holistic face-to-face assessment and treatment to those with respiratory symptoms in an environment with strict protocols for infection prevention and control. This ensures that these patients are able to access high quality primary care while protecting the general practice workforce and other patients. The GP respiratory clinic model was developed and operationalized 10 days after the policy was announced, with the first 2 respiratory clinics opening on March 21, 2020. Subsequently a total of 150 respiratory clinics were opened and served over 800,000 patients within more than 99% of Australia’s postcodes. These clinics used a standardized data collection tool that has provided the largest and most complete primary care surveillance database of respiratory illness in Australia. The success of the GP respiratory clinic model was made possible due to strong partnerships with Primary Health Networks and individual general practices that rapidly shifted operations to embrace this new approach. This article describes the development and early implementation of this model.","PeriodicalId":22305,"journal":{"name":"The Annals of Family Medicine","volume":"53 1","pages":"273 - 276"},"PeriodicalIF":0.0,"publicationDate":"2022-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"74170322","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
F. J. Rodríguez-Contreras, Antonio Calvo-Cebrián, Juncal Díaz-Lázaro, M.L. Cruz-Arnes, Fernando León-Vázquez, María del Carmen Lobón-Agúndez, Francisco Javier Palau-Cuevas, Paloma Henares-García, Fernando Gavilán-Martínez, S. Fernández-Plaza, Carmelo Prieto-Zancudo
PURPOSE We investigated whether lung ultrasound (US) performed in primary care is useful and feasible for diagnosing community-acquired pneumonia (CAP) compared with chest radiography, as most previous research has been conducted in hospital settings. METHODS We undertook a prospective observational cohort study of lung US performed in 12 primary care centers. Patients aged 5 years and older with symptoms suggesting CAP were examined with lung US (by 21 family physicians and 7 primary care pediatricians) and chest radiograph on the same day. We compared lung US findings with the radiologist’s chest radiograph report as the reference standard, given that the latter is the most common imaging test performed for suspected CAP in primary care. The physicians had varied previous US experience, but all received a 5-hour lung US training program. RESULTS The study included 82 patients. Compared with chest radiography, positive lung US findings (consolidation measuring >1 cm or a focal/asymmetrical B-lines pattern) showed a sensitivity of 87.8%, a specificity of 58.5%, a positive likelihood-ratio of 2.12, and a negative likelihood-ratio of 0.21. Findings were similar regardless of the physicians’ previous US training or experience. We propose a practical algorithm whereby patients having consolidation measuring greater than 1 cm or normal findings on lung US could skip chest radiography, whereas patients with a B-lines pattern without consolidation (given its low specificity) would need chest radiography to ensure appropriate management. Lung US was generally performed in 10 minutes or less. CONCLUSION Point-of-care lung US in primary care could be useful for investigating suspected CAP (avoiding chest radiography in most cases) and is likely feasible in daily practice, as short training programs appear sufficient and little time is needed to perform the scan.
{"title":"Lung Ultrasound Performed by Primary Care Physicians for Clinically Suspected Community-Acquired Pneumonia: A Multicenter Prospective Study","authors":"F. J. Rodríguez-Contreras, Antonio Calvo-Cebrián, Juncal Díaz-Lázaro, M.L. Cruz-Arnes, Fernando León-Vázquez, María del Carmen Lobón-Agúndez, Francisco Javier Palau-Cuevas, Paloma Henares-García, Fernando Gavilán-Martínez, S. Fernández-Plaza, Carmelo Prieto-Zancudo","doi":"10.1370/afm.2796","DOIUrl":"https://doi.org/10.1370/afm.2796","url":null,"abstract":"PURPOSE We investigated whether lung ultrasound (US) performed in primary care is useful and feasible for diagnosing community-acquired pneumonia (CAP) compared with chest radiography, as most previous research has been conducted in hospital settings. METHODS We undertook a prospective observational cohort study of lung US performed in 12 primary care centers. Patients aged 5 years and older with symptoms suggesting CAP were examined with lung US (by 21 family physicians and 7 primary care pediatricians) and chest radiograph on the same day. We compared lung US findings with the radiologist’s chest radiograph report as the reference standard, given that the latter is the most common imaging test performed for suspected CAP in primary care. The physicians had varied previous US experience, but all received a 5-hour lung US training program. RESULTS The study included 82 patients. Compared with chest radiography, positive lung US findings (consolidation measuring >1 cm or a focal/asymmetrical B-lines pattern) showed a sensitivity of 87.8%, a specificity of 58.5%, a positive likelihood-ratio of 2.12, and a negative likelihood-ratio of 0.21. Findings were similar regardless of the physicians’ previous US training or experience. We propose a practical algorithm whereby patients having consolidation measuring greater than 1 cm or normal findings on lung US could skip chest radiography, whereas patients with a B-lines pattern without consolidation (given its low specificity) would need chest radiography to ensure appropriate management. Lung US was generally performed in 10 minutes or less. CONCLUSION Point-of-care lung US in primary care could be useful for investigating suspected CAP (avoiding chest radiography in most cases) and is likely feasible in daily practice, as short training programs appear sufficient and little time is needed to perform the scan.","PeriodicalId":22305,"journal":{"name":"The Annals of Family Medicine","volume":"137 1","pages":"227 - 236"},"PeriodicalIF":0.0,"publicationDate":"2022-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"89146519","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"STFM TASK FORCE RELEASES A STANDARDIZED FAMILY MEDICINE SUB-INTERNSHIP CURRICULUM","authors":"Emily Walters, Tomoko Sairenji","doi":"10.1370/afm.2839","DOIUrl":"https://doi.org/10.1370/afm.2839","url":null,"abstract":"","PeriodicalId":22305,"journal":{"name":"The Annals of Family Medicine","volume":"18 1","pages":"289 - 290"},"PeriodicalIF":0.0,"publicationDate":"2022-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"74086246","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
S. Mitchell, Matthew Reichert, J. Howard, Katherine Krizman, Alexa Bragg, Molly Huffaker, Kimberly N Parker, Mary Cawley, Hannah Webb Roberts, Yena Sung, Jennifer Brown, L. Culpepper, H. Cabral, Brian W. Jack
PURPOSE To determine if hospitalized patients with depressive symptoms will benefit from post-discharge depression treatment with care transition support. METHODS This is a randomized controlled trial of hospitalized patients with patient health questionnaire-9 score of 10 or more. We delivered the Re-Engineered Discharge (RED) and randomized participants to groups receiving RED-only or RED for Depression (RED-D), a 12-week post-discharge telehealth intervention including cognitive behavioral therapy, self-management support, and patient navigation. Primary outcomes were hospital readmission and reutilization rates at 30 and 90 days post discharge. RESULTS We randomized 709 participants (353 RED-D, 356 RED-only). At 90 days, 265 (75%) intervention participants had received at least 1 RED-D session (median 4). At 30 days, the intention-to-treat analysis showed no differences between RED-D vs RED-only in hospital readmission (9% vs 10%, incidence rate ratio [IRR] 0.92 [95% CI, 0.56-1.52]) or reutilization (27% vs 24%, IRR 1.14 [95% CI, 0.85-1.54]). The intention-to-treat analysis also showed no differences at 90 days in readmission (28% vs 21%, IRR 1.30 [95% CI, 0.95-1.78]) or reutilization (70% vs 57%, IRR 1.22 [95% CI, 1.01-1.49]). In the as-treated analysis, each additional RED-D session was associated with a decrease in 30- and 90-day readmissions. At 30 days, among 104 participants receiving 3 or more sessions, there were fewer readmissions (3% vs 10%, IRR 0.30 [95% CI, 0.07-0.84]) compared with the control group. At 90 days, among 109 participants receiving 6 or more sessions, there were fewer readmissions (11% vs 21%, IRR 0.52 [95% CI, 0.27-0.92]). Intention-to-treat analysis showed no differences between study groups on secondary outcomes. CONCLUSIONS Care transition support and post-discharge depression treatment can reduce unplanned hospital use with sufficient uptake of the RED-D intervention.
目的:确定有抑郁症状的住院患者是否能从出院后抑郁治疗和护理过渡支持中获益。方法:本研究是一项随机对照试验，纳入患者健康问卷-9得分在10分及以上的住院患者。我们进行了重新设计出院(RED)，并将参与者随机分为仅接受RED或接受RED for Depression (RED- d)的组，这是一项为期12周的出院后远程医疗干预，包括认知行为治疗、自我管理支持和患者导航。主要结局是出院后30天和90天的再入院率和再利用率。结果:我们随机分配了709名参与者(353名RED-D, 356名RED-only)。在第90天，265名(75%)干预参与者接受了至少1次RED-D治疗(中位数为4次)。在第30天，意向治疗分析显示，RED-D治疗与RED-D治疗在再入院(9% vs 10%，发病率比[IRR] 0.92 [95% CI, 0.56-1.52])或再利用率(27% vs 24%， IRR 1.14 [95% CI, 0.85-1.54])方面没有差异。意向治疗分析也显示，90天的再入院率(28%对21%，IRR 1.30 [95% CI, 0.95-1.78])或再使用率(70%对57%，IRR 1.22 [95% CI, 1.01-1.49])无差异。在治疗后的分析中，每增加一次RED-D治疗与30天和90天再入院的减少有关。在第30天，接受3次或以上治疗的104名参与者中，与对照组相比，再入院人数较少(3% vs 10%， IRR 0.30 [95% CI, 0.07-0.84])。在第90天，109名接受6次或更多疗程的参与者中，再入院人数较少(11%对21%，IRR 0.52 [95% CI, 0.27-0.92])。意向治疗分析显示两组在次要结局上没有差异。结论:充分采用RED-D干预措施，护理过渡支持和出院后抑郁治疗可减少计划外住院。
{"title":"Reducing Readmission of Hospitalized Patients With Depressive Symptoms: A Randomized Trial","authors":"S. Mitchell, Matthew Reichert, J. Howard, Katherine Krizman, Alexa Bragg, Molly Huffaker, Kimberly N Parker, Mary Cawley, Hannah Webb Roberts, Yena Sung, Jennifer Brown, L. Culpepper, H. Cabral, Brian W. Jack","doi":"10.1370/afm.2801","DOIUrl":"https://doi.org/10.1370/afm.2801","url":null,"abstract":"PURPOSE To determine if hospitalized patients with depressive symptoms will benefit from post-discharge depression treatment with care transition support. METHODS This is a randomized controlled trial of hospitalized patients with patient health questionnaire-9 score of 10 or more. We delivered the Re-Engineered Discharge (RED) and randomized participants to groups receiving RED-only or RED for Depression (RED-D), a 12-week post-discharge telehealth intervention including cognitive behavioral therapy, self-management support, and patient navigation. Primary outcomes were hospital readmission and reutilization rates at 30 and 90 days post discharge. RESULTS We randomized 709 participants (353 RED-D, 356 RED-only). At 90 days, 265 (75%) intervention participants had received at least 1 RED-D session (median 4). At 30 days, the intention-to-treat analysis showed no differences between RED-D vs RED-only in hospital readmission (9% vs 10%, incidence rate ratio [IRR] 0.92 [95% CI, 0.56-1.52]) or reutilization (27% vs 24%, IRR 1.14 [95% CI, 0.85-1.54]). The intention-to-treat analysis also showed no differences at 90 days in readmission (28% vs 21%, IRR 1.30 [95% CI, 0.95-1.78]) or reutilization (70% vs 57%, IRR 1.22 [95% CI, 1.01-1.49]). In the as-treated analysis, each additional RED-D session was associated with a decrease in 30- and 90-day readmissions. At 30 days, among 104 participants receiving 3 or more sessions, there were fewer readmissions (3% vs 10%, IRR 0.30 [95% CI, 0.07-0.84]) compared with the control group. At 90 days, among 109 participants receiving 6 or more sessions, there were fewer readmissions (11% vs 21%, IRR 0.52 [95% CI, 0.27-0.92]). Intention-to-treat analysis showed no differences between study groups on secondary outcomes. CONCLUSIONS Care transition support and post-discharge depression treatment can reduce unplanned hospital use with sufficient uptake of the RED-D intervention.","PeriodicalId":22305,"journal":{"name":"The Annals of Family Medicine","volume":"101 2 1","pages":"246 - 254"},"PeriodicalIF":0.0,"publicationDate":"2022-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"78048265","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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