LESSONS LEARNED AND STRATEGIES FOR RECRUITMENT OF DIVERSE, LOW-INCOME PATIENTS INTO AN INTEGRATIVE MEDICAL GROUP VISIT CLINICAL TRIAL
EXPLORE-THE JOURNAL OF SCIENCE AND HEALING
2019; 15 (3): 215?21
Description of recruitment methods and lessons learned in a randomized controlled trial of underserved patients using an integrative medical group visits intervention.Comparison of the demographic characteristics of participants screened and consented to the study as well as description of recruitment methods used.This paper examines the characteristics of patients who were eligible compared to those who were not, characteristics of patients at the different sites, and patient characteristics over time (by comparing various cohorts) based on our experiences recruiting underserved patients.We screened 338 patients, with 205 (60.6%) meeting eligibility criteria and 159 patients randomized and consented. 133 patients were found ineligible, with the most common reasons being low depression scores (n?=?20), manic symptoms (n?=?20), and psychotic symptoms (n?=?19), and alcohol use (n?=?15). We found demographic differences in patients recruited by different methods and at different sites- patients referred by provider letter were older than those referred by self-referral or provider referral (mean age/SD vs. mean age/SD, p?=?0.0001). For site-specific differences, patients at DH were older (53 SD?=?12.3) than those at the Boston Medical Center (49 SD?=?11.3) and CSHC (p?=?0.048) in pair-wise comparisons. Patients at DH were also more likely to be white (25%) as compared to BMC (18%) and DH (7%), while those at CSHC were more likely to be black (70%) (p?=?0.008).
View details for DOI 10.1016/j.explore.2019.01.003
View details for Web of Science ID 000474328500008
View details for PubMedID 31056423
Health Disparities in Access to Nonpharmacologic Therapies in an Urban Community
JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE
2019; 25 (1): 48?60
The overuse of prescription opioids for chronic pain is recognized as a public health crisis. Yet, poor access to nonpharmacologic treatments is the norm in low-income, racially and ethnically diverse patients with chronic pain. The main objective of this study was to understand how chronic pain impacts low-income individuals with chronic pain and their communities from multiple perspectives.This was a qualitative study using a Science Café methodology.The Science Café event was held at an urban community center in Boston, MA.Inclusion criteria included the following: having the ability to attend the event, being at least 18 years of age or older, and participating in English.Data were collected through self-reported questionnaires and audio or video recordings of two focus groups. Quantitative and qualitative data were analyzed with SAS 9.3 and NVivo 10.Thirty participants attended the Science Café event. The average age was 45 years, 77% reported as female, 42% identified as black, and 19% as Hispanic. Participants identified themselves as either patients (46%) or providers (54%) to the chronic pain community. Our forum revealed three major themes: (1) nonpharmacologic options for chronic pain management are warranted, (2) larger sociodemographic and contextual factors influence management of chronic pain, and (3) both patients and providers value the patient-provider relationship and acknowledge the need for better communication for patients with chronic pain.Future research should consider identifying and addressing disparities in access to nonpharmacologic treatments for chronic pain in relation to underlying social determinants of health, particularly for racially and ethnically diverse patients.
View details for DOI 10.1089/acm.2018.0217
View details for Web of Science ID 000445089600001
View details for PubMedID 30234363
The Latino Integrative Medical Group Visit as a Model for Pain Reduction in Underserved Spanish Speakers
JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE
2018; 24 (2): 125?31
Chronic pain is a common problem in the United States, one for which there is a dearth of effective treatments. Nonpharmacological options are a promising alternative, especially for Spanish-speaking Latinos. This pilot study would like to assess the feasibility of an adapted Integrative Medical Group Visit (IMGV) curriculum for a Spanish-speaking Latino chronic pain population.We translated and adapted the curriculum of the IMGV for a Spanish-speaking Latino chronic pain population. We then tested the feasibility of using this model with two pilot groups (N?=?19) using a pre-postdesign.This intervention was targeted for underserved Spanish-speaking Latino patients with chronic pain.This study took place at a safety net academic teaching hospital, the Boston Medical Center, and at a community health center located in a majority Latino neighborhood, the East Boston Neighborhood Health Clinic.We used the validated Spanish translations of the Patient-Reported Outcomes Measurement Information System (PROMIS-29) (short version), Personal Health Questionnaire (PHQ-8), and Perceived Stress Scale (PSS-10). We also gathered qualitative information through focus groups and in-depth interviews.Using PROMIS measures, there was a statistically significant reduction in pain interference (p?=?0.01), fatigue (p?=?0.01), and depression (p?=?0.01). Qualitative data also indicated the participants felt they benefited from the visits and having care in Spanish was unique.This model offers a promising nonpharmacological option for Spanish-speaking patients with chronic pain and could offer an alternative for addressing disparities for this population.
View details for DOI 10.1089/acm.2017.0132
View details for Web of Science ID 000424783100006
View details for PubMedID 28885858
Living with chronic pain: Evaluating patient experiences with a medical group visit focused on mindfulness and non-pharmacological strategies
COMPLEMENTARY THERAPIES IN MEDICINE
2017; 35: 33?38
Little is known about the acceptance of non-pharmacological group strategies delivered to low income racially diverse patients with chronic pain and depression. This paper examines how the Integrative Medical Group Visit (IMGV) addresses many of the deficits identified with usual care.Six IMGVs cohorts were held at a safety net hospital and two federally funded community health centres. Data was gathered through focus groups. Transcripts were analysed using both a priori codes and inductive coding.The intervention included ten sessions of Integrative Medical Group Visits with a primary care provider and a meditation instructor. The curriculum uses principles of Mindfulness Based Stress Reduction and evidence based integrative medicine. The visit is structured similarly to other group medical visits.Data was gathered through four focus groups held after the cohorts were completed.Participants (N=20) were largely low income minority adults with chronic pain and comorbid depression. Six themes emerged from the coding including: chronic pain is isolating; group treatment contributes to better coping with pain; loss of control and autonomy because of the unpredictability of pain as well as dependence on medication and frequent medical appointments; groups improve agency and control over one's health condition; navigating the healthcare system and unsatisfactory treatment options; and changes after the IMGV due to non-pharmacological health management.The IMGV is a promising format of delivering integrative care for chronic pain and depression which addresses many of the problems identified by patients in usual care.
View details for DOI 10.1016/j.ctim.2017.09.002
View details for Web of Science ID 000418221800007
View details for PubMedID 29154064
Design of the integrative medical group visits randomized control trial for underserved patients with chronic pain and depression
CONTEMPORARY CLINICAL TRIALS
2017; 54: 25?35
Given the public health crisis of opioid overprescribing for pain, there is a need for evidence-based non pharmacological treatment options that effectively reduce pain and depression. We aim to examine the effectiveness of the Integrative Medical Group Visits (IMGV) model in reducing chronic pain and depressive symptoms, as well as increasing pain self-management.This paper details the study design and implementation of an ongoing randomized controlled trial of the IMGV model as compared to primary care visits. The research aims to determine if the IMGV model is effective in achieving: a) a reduction in self-reported pain and depressive symptoms and 2) an improvement in the self-management of pain, through increasing pain self-efficacy and reducing use of self-reported pain medication. We intend to recruit 154 participants to be randomized in our intervention, the IMGV model (n=77) and to usual care (n=77).Usual care of chronic pain through pharmacological treatment has mixed evidence of efficacy and may not improve quality of life or functional status. We aim to conduct a randomized controlled trial to evaluate the effectiveness of the IMGV model as compared to usual care in reducing self-reported pain and depressive symptoms as well as increasing pain management skills.
View details for DOI 10.1016/j.cct.2016.12.013
View details for Web of Science ID 000394557500004
View details for PubMedID 27979754
- Augmenting Group Medical Visits with Conversational Agents for Stress Management Behavior Change SPRINGER INTERNATIONAL PUBLISHING AG. 2017: 55?67
- Blissful Agents: Adjuncts to Group Medical Visits for Chronic Pain and Depression SPRINGER-VERLAG BERLIN. 2016: 433?37
The Costs and Benefits of Reducing Racial-Ethnic Disparities in Mental Health Care
2015; 66 (4): 389?96
Previous studies have found that timely mental health treatment can result in savings in both mental health and general medical care expenditures. This study examined whether reducing racial-ethnic disparities in mental health care offsets costs of care.Data were from a subsample of 6,206 individuals with probable mental illness from the 2004-2010 Medical Expenditure Panel Survey (MEPS). First, disparities in mental health treatment were analyzed. Second, two-year panel data were used to determine the offset of year 1 mental health outpatient and pharmacy treatment on year 2 mental and general medical expenditures. Third, savings were estimated by combining results from steps 1 and 2.Compared with whites, blacks and Latinos with year 1 outpatient mental health care spent less on inpatient and emergency general medical care in year 2. Latinos receiving mental health care in year 1 spent less than others on inpatient general medical care in year 2. Latinos taking psychotropic drugs in year 1 showed reductions in inpatient general medical care. Reducing racial-ethnic disparities in mental health care and in psychotropic drug use led to savings in acute medical care expenditures.Savings in acute care expenditures resulting from eliminating disparities in racial-ethnic mental health care access were greater than costs in some but not all areas of acute mental health and general medical care. For blacks and Latinos, the potential savings from eliminating disparities in inpatient general medical expenditures are substantial (as much as $1 billion nationwide), suggesting that financial and equity considerations can be aligned when planning disparity reduction programs.
View details for DOI 10.1176/appi.ps.201400070
View details for Web of Science ID 000370687300010
View details for PubMedID 25588417
View details for PubMedCentralID PMC7595243
Effectiveness of the Engagement and Counseling for Latinos (ECLA) Intervention in Low-income Latinos
2014; 52 (11): 989?97
Persistent disparities in access and quality of mental health care for Latinos indicate a need for evidence-based, culturally adapted, and outside-the-clinic-walls treatments.Evaluate treatment effectiveness of telephone (ECLA-T) or face-to-face (ECLA-F) delivery of a 6-8 session cognitive behavioral therapy and care management intervention for low-income Latinos, as compared to usual care for depression.Multisite randomized controlled trial.Eight community health clinics in Boston, Massachusetts and San Juan, Puerto Rico.257 Latino patients recruited from primary care between May 2011 and September 2012.The primary outcome was severity of depression, assessed with the Patient Health Questionnaire-9 and the Hopkins Symptom Checklist-20. The secondary outcome was functioning over the previous 30 days, measured using the World Health Organization Disability Assessment Schedule (WHO-DAS 2.0).Both telephone and face-to-face versions of the Engagement and Counseling for Latinos (ECLA) were more effective than usual care. The effect sizes of both intervention conditions on Patient Health Questionnaire-9 were moderate when combined data from both sites are analyzed (0.56 and 0.64 for face-to-face and telephone, respectively). Similarly, effect sizes of ECLA-F and ECLA-T on the Hopkins Symptom Checklist were quite large in the Boston site (0.64 and 0.73. respectively) but not in Puerto Rico (0.10 and 0.03).The intervention appears to help Latino patients reduce depressive symptoms and improve functioning. Of particular importance is the higher treatment initiation for the telephone versus face-to-face intervention (89.7% vs. 78.8%), which suggests that telephone-based care may improve access and quality of care.
View details for DOI 10.1097/MLR.0000000000000232
View details for Web of Science ID 000343930300009
View details for PubMedID 25310525
View details for PubMedCentralID PMC4201237
Activation, Self-management, Engagement, and Retention in Behavioral Health Care A Randomized Clinical Trial of the DECIDE Intervention
2014; 71 (5): 557?65
Given minority patients' unequal access to quality care, patient activation and self-management strategies have been suggested as a promising approach to improving mental health care.To determine whether the DECIDE (Decide the problem; Explore the questions; Closed or open-ended questions; Identify the who, why, or how of the problem; Direct questions to your health care professional; Enjoy a shared solution) intervention, an educational strategy that teaches patients to ask questions and make collaborative decisions with their health care professional, improves patient activation and self-management, as well as engagement and retention in behavioral health care.In this multisite randomized clinical trial performed from February 1, 2009, through October 9, 2011 (date of last follow-up interview), we recruited 647 English- or Spanish-speaking patients 18 to 70 years old from 13 outpatient community mental health clinics across 5 states and 1 US territory. A total of 722 patients were included in analyses of secondary outcomes.Three DECIDE training sessions delivered by a care manager vs giving patients a brochure on management of behavioral health.Primary outcomes were patient assessment of activation (Patient Activation Scale) and self-management (Perceived Efficacy in Patient-Physician Interactions). Secondary outcomes included patient engagement (proportion of visits attended of those scheduled) and retention (attending at least 4 visits in the 6 months after the baseline research assessment), collected through medical record review or electronic records.Patients assigned to DECIDE reported significant increases in activation (mean ??=?1.74, SD?=?0.58; P?=?.003) and self-management (mean ??=?2.42, SD?=?0.90; P?=?.008) relative to control patients, but there was no evidence of an effect on engagement or retention in care.The DECIDE intervention appears to help patients learn to effectively ask questions and participate in decisions about their behavioral health care, but a health care professional component might be needed to augment engagement in care. DECIDE appears to have promise as a strategy for changing the role of minority patients in behavioral health care.clinicaltrials.gov Identifier: NCT01226329
View details for DOI 10.1001/jamapsychiatry.2013.4519
View details for Web of Science ID 000335947600013
View details for PubMedID 24647680
View details for PubMedCentralID PMC4311517
Revisiting the evidence on health and health care disparities among the Roma: a systematic review 2003-2012
INTERNATIONAL JOURNAL OF PUBLIC HEALTH
2013; 58 (6): 885?911
To conduct a systematic review of the epidemiological and health service utilization literature related to the Roma population between 2003 and 2012.Systematic review of empirical research related to Roma health and health care utilization published between 2003 and 2012 identified through electronic databases (PsycInfo, Medline, Google Scholar). Methodological rigor was evaluated using a six-point set of design criteria.We found evidence for lower self-reported health and significantly higher mortality risk for Roma compared to non-Roma, and greater prevalence of health risk factors for Roma children, including environmental risks, low birth weight, and lower vaccination coverage. Studies of non-communicable and infectious disease remain insufficient to make firm conclusions on disparities. Barriers to care include lack of documentation and affordability of care, though more studies on health care utilization are needed.Roma youth and adults are in need of programs that reduce health disparities and their increased mortality risk. Reducing exposure to risk factors such as smoking, obesity, and poor living conditions may be a target for interventions. More intervention studies and rigorous evaluations are needed.
View details for DOI 10.1007/s00038-013-0518-6
View details for Web of Science ID 000327858000011
View details for PubMedID 24096986