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2.
Postgraduate Medicine ; 134(Supplement 2):87-89, 2022.
Article in English | EMBASE | ID: covidwho-2087437

ABSTRACT

Learning Objectives (1) Describe the components of the VHA Whole Health framework in relation to the biopsychosocial model of pain. (2) Identify the contributions of various disciplines/roles to interdisciplinary care for chronic pain (interventional pain, psychology, dietitian, pharmacy, physical therapy). (3) Explain the importance of involving various stakeholders (i.e. patients, administration) when developing and implementing a novel clinical program. Purpose The Joint Commission and Veterans Health Administration (VHA) require VA Medical Centers to offer interdisciplinary (IDT) evaluations of chronic pain, which are associated with improvements in provider and staff satisfaction, decreased ER visits, increased quality of life, lower overutilization of healthcare services, decreased disability related to pain and impact of pain, decrease symptoms mental health difficulties (i.e. anxiety, depression, stress), and increased selfefficacy for patients. However, there is significant variability in models of programming and no evidence-based implementation strategies have been studied. Many VAs, including Salem VAMC, adopted a consultative model of IDT which typically involve one appointment with multiple providers (typically interventional pain, psychology, physical therapy, and pharmacy) who make chart recommendations before the patients return to their PCP. This model does not include follow-up appointments and follow-through with recommendations from the IDT team are not guaranteed once they return to their referring provider. At the other end of the spectrum, each region in VHA is expected to offer a Commission on Accreditation of Rehabilitation Facilities (CARF) accredited Interdisciplinary Pain Rehabilitation Program (IPRP), which typically involves patient participation in programming for approximately forty hours per week for six weeks (i.e. over 100 hours of provider-led service). Given the staffing shortages related to the COVID pandemic and the amount of effort required by patients, implementing the IPRP model can be challenging. To overcome these patient and provider barriers to effective pain management, the PREVAIL Program for Chronic Pain was developed and implemented at the Salem VAMC, which serves primarily rural Veterans. PREVAIL utilizes the VHA's Whole Health framework to develop patient-centered, biopsychosocial treatment plans tailored to Veteran preferences. These plans emphasize active self-management of chronic pain, nonpharmacological strategies, involve low burden for patients and the healthcare system, and allow the Veteran to choose three of the following Whole Health self-care areas to focus on during their 6-month participation in PREVAIL: Power of the Mind, Recharge, Surroundings, Moving the Body, Family, Friends, and Coworkers, Food and Drink, Spirit and Soul, and Personal Development. This work describes the phases of development and implementation of PREVAIL. Methods A multiphase approach was used to iteratively assess and refine the PREVAIL program. Participants were thirty-six Veterans with chronic pain who had completed at least half of six pain education classes offered by the pain department at the Salem VA Medical Center. The a priori aims of the IDT process adaptations were to increase the efficiency of care/ decrease patient burden (number of appointments needed by Veterans to establish a biopsychosocial treatment plan for chronic pain), lower healthcare system burden (number of minutes spent by PCP's placing pain consults, number of scheduling calls needed), and increase access to care (wait time for first pain intervention). Implementation was conducted through 3 phases that included varying lengths of the IDT appointment and inclusion of Complementary and Integrative Health (CIH) modalities. During the preparation phase, a psychologist who was not part of the original IDT program (i.e. third party interview) who was trained in sound qualitative methodologies interviewed 5 providers who had placed referrals to the previous consultative model of IDT at the Salem VAMC. Dur ng phase 1 of the new IDT rollout, 9 Veterans completed a 4-hour appointment which included participation in a 1 hour shared IDT appointment (interventional pain, psychology, dietary, pharmacy, physical therapy) and 3 hours of CIH modalities. Using feedback from stakeholders, Phase 2 of the IDT rollout included 27 Veterans who completed a 90-minute shared appointment with the IDT team (aforementioned five disciplines). Stakeholder feedback led to the third phase of IDT rollout, which included a 60- minute shared appointment with the IDT (5 disciplines aforementioned). Each phase also included Veterans receiving monthly phone calls with a whole health coach who used motivational interviewing (MI) techniques to discuss successes, resolve barriers, and establish new goals. A 6-month follow up appointment with the IDT team assessed progress toward their initial goals and changes over time in selfreported measures. Measures were the number of Veterans appointments, time PCPs spent placing consults, number of scheduling calls, wait time for interventions, the three areas of self-care Veterans elected to focus on their participation in the program, and a program-specific patient satisfaction survey. Results Referring providers were satisfied with the following elements of the previous consultative model that was used prior to PREVAIL: Medication recommendations from Pharmacy and Pain MD, inclusion of a face-to-face physical examination, provision of an individualized treatment plan, good follow through from interventional pain, provision of suboxone prescriptions, and involvement of mental health on IDT team. Referring providers were dissatisfied with the lack of communication and follow through of recommendations resulting from the consultative model of IDT. They also noted confusion about the goals of the consultative model, concern about lack of patient buy-in for nonpharmacological strategies to manage pain, and a strong preference for the pain department to prescribe opioid medication. Stakeholder feedback (i.e. patient, administration, PREVAIL providers) were incorporated between phases of PREVAIL implementation. While patients often stated their favorite aspect of the appointment was time with the IDT team, converting to a 60-minute model based on administration preference for reduced use of resources did not decrease patient satisfaction. PREVAIL led to a number of improvements in outcomes of interest. The implementation of PREVAIL IDT decreased the number of appointments needed by Veterans to establish a biopsychosocial treatment plan for chronic pain decreased from 5 to 1, decreased the number of minutes spent by PCP's placing pain-related consults reduced from 10 to 2, decreased the number of scheduling calls needed reduced from 5 to 1, and wait time for first pain intervention decreased from 55 days to 14 days. Results of satisfaction surveys from both Veterans and caregivers were as follows: 100% reported 'providers treated me with respect and courtesy,' 100% agreed or strongly agreed they understood their role in actively self-managing pain, 100% stated the IDT evaluation was a valuable use of their time, and 100% would recommend the IDT evaluation to a friend. The average overall satisfaction for the IDT evaluation was 9/10. The majority of patients chose to focus on Power of the Mind (thoughts and emotional health;72%) and Moving the Body (exercise and movement;67%) as one of their top 3 areas of Whole Health framework to focus on, while 25% preferred to focus on Food and Drink (dietary changes). Conclusion This study provides preliminary evidence that the implementation of PREVAIL IDT decreased the burden to patients and the healthcare system, as well as access to care. These preliminary results suggest IDT models that offer follow-up appointments to patients may not require the healthcare and patient burden of weeks of programming (i.e. IPRP), as PREVAIL was acceptable to both providers and Veterans. Regarding lessons learned, eliciting feedback from patients, referring providers, treating providers, and adm nistrators was crucial in creating a rich clinical experience that wisely utilized limited resources in the midst of a pandemic. Furthermore, while traditional IDT models do not include a dietitian, this study provides evidence that Veterans with chronic pain at the Salem VAMC have an interest in follow-up nutrition services and report a high level of satisfaction with the service when dietitians are included on the IDT. Future studies should examine the efficacy of PREVAIL on physical functioning and mental health symptoms compared to established models (IPRP's, consultative models), the cost effectiveness of PREVAIL, and longitudinal outcomes associated with participation in PREVAIL.

3.
Gynecologic Oncology ; 166:S251, 2022.
Article in English | EMBASE | ID: covidwho-2031758

ABSTRACT

Objectives: To determine (1) if health disparities experienced by rural, obese endometrial cancer survivors (ECS) were exacerbated by the COVID-19 pandemic and (2) preferred components and delivery methods for behavioral interventions. Methods: A cross-sectional survey was distributed to obese, early- stage ECS to ascertain demographic information, physical activity (PA level), self-efficacy, lifestyle intervention preferences, as well as the impact of COVID-19 on PA, diet, and mental health. Responses were compared between obese (BMI= 30-39.9 kg/m2) and morbidly obese (BMI= 40+ kg/m2) survivors as well as those who did or did not meet national PA recommendations. Results: Among 335 eligible survivors, only 70 (20.9%) completed the survey. The median age was 63 years (IQR: 14 years). Survivors were 37 months from diagnosis (IQR: 37 months). The median BMI was 39.2 kg/m2 (IQR: 8.4 kg/m2). Overall, only one-quarter of ECS were fairly or fully confident in their ability to undertake moderate PA. More morbidly obese survivors reported low self-efficacy in performing moderate PA than obese survivors (90% vs 65%;p= 0.02). Pre COVID-19, 66% of survivors did not meet PA guidelines and were more likely to be morbidly obese than obese, but the difference was not significant (78% vs 58%;p=0.08). Post COVID-19, 83% of survivors did not meet PA guidelines, with no difference between BMI groups (82% vs 84%;p>0.05). After COVID-19, 54% of survivors reported a decrease in PA, 32% made poorer nutritional choices, and 47% reported worsening mental health. Post COVID-19, no difference in the nutrition or mental health changes was seen between survivors who were meeting PA guidelines and those who were not (p>0.05). Regarding lifestyle interventions, survivors preferred information delivered electronically (online (56%) or via email (41%)) versus in person (30%) or via text (21%). Preferences for PA included exercising at home (46%) or online with a coach (33%) versus with a group fitness class (18%) or at the gym (17%). Combining health promotion with exercise was appealing to the majority of participants (37%), while others were not interested (27%) or unsure (31%). Responses were similar between patients meeting and not meeting PA recommendations (p>0.05). The most preferred lifestyle intervention components included tracking progress (56%), health recipes (56%), one-on-one counseling (46%), tips for cheap and healthy eating (41%), exercising alone (41%), and online sessions (39%). Conclusions: As a result of COVID-19, rural, obese ECS experienced a decrease in PA, worse nutritional decision-making, and poorer mental health. Preferred components of lifestyle interventions in this patient population were identified and can be used to develop future, evidence-based behavioral interventions. These interventions may be scalable in rural communities with limited access during the COVID-19 pandemic and beyond.

4.
Cancer Research ; 82(12), 2022.
Article in English | EMBASE | ID: covidwho-1986509

ABSTRACT

African Americans (AA) have higher incidence and mortality rates for several cancer types in comparison to their European American (EA) counterparts. Increasing participation in clinical research and patient registries, related to precision cancer medicine, will significantly improve cancer health equity. Many AA cancer patients are treated in community oncology clinics. Unfortunately, these health systems have limited access to Clinical Laboratory Improvement Amendments (CLIA) next generation sequence (NGS) germline and somatic DNA and RNA testing that are used to inform oncologists on the best treatment and/or clinical trial options for cancer patients. Indeed, AA CLIA NGS sample sets are poorly represented, which could presumably result in incomplete knowledge of genomic variants that could affect their treatment and overall outcomes. Hence, it is crucial to implement CLIA NGS efforts for all cancer patients. To address these disparities, Morehouse School of Medicine has formed the Comprehensive Approach to Reimagine health Equity Solutions (CARhES) consortium with Tuskegee University that has engaged community oncology practices in Alabama and Georgia - two of five Black Belt states. The CARhES consortium aims to implement precision cancer medicine to underserved and underrepresented communities that will improve the standard of cancer care by providing access to CLIA NGS testing, clinical trials, and personalized cancer care. Here we describe the first proof of concept of this approach with community oncology partners, i.e., Grady Health System, Wellstar Health System, Georgia Urology, Midtown Urology, and Maui Memorial Medical Center. At the time of consent, saliva, buccal, and tumor samples were collected from participants. Germline and somatic CLIA NGS was performed, and medical reports were returned to practitioners within 14 days. Prior to the COVID pandemic, the study enrolled over 880 patients with a 88% consent rate (n = 1000) in the first 11months of the program. At the start of the COVID pandemic, recruitment efforts were suspended for four months with a slow restart by June 2020. A decrease in the number of staff, office visits (67% reduction), and increase in COVID cases significantly limited recruitment efforts. During this slowdown, we established and improved eConsenting capabilities, which exist today. Community anxiety, due to the pandemic and SARS-CoV-19 vaccine efforts, resulted in a significant reduction in consent rates (88% to 60%). Nevertheless, this study began in April of 2019 and consented 1,750 participants in less than 2 years. Taken together, our study shows that a community-focused precision medicine approach requires meeting people where they are and providing them with access and understanding the benefit of clinical trial participation. The approximate 2,000 clinically annotated genomic AA datasets will greatly contribute to our understanding of cancer health disparities and among the first steps to democratize precision medicine.

5.
Clin Radiol ; 76(7): 549.e9-549.e15, 2021 07.
Article in English | MEDLINE | ID: covidwho-1163597

ABSTRACT

AIM: To obtain a national snapshot of radiology trainees' experience during the first wave of the pandemic. MATERIALS AND METHODS: A 25-item questionnaire was disseminated to representatives from all training regions across the UK in July 2020. Each representative collated the collective experiences of trainees in their training programme in key domains, including redeployment, shielding, training, and teaching. RESULTS: Ninety-five percent (38 of 40) of representatives completed the questionnaire. Trainees in up to 76% of training programmes were redeployed to wards and some trainees were shielding in 81% of programmes. Only 27% of programmes enabled remote reporting for isolating or shielding trainees. Sixty-two percent of respondents felt their well-being needs were supported. There was an overall increase in the attendance, volume, and quality of teaching and training nationally due to improved accessibility via remote-learning methods. Significant challenges were described with reporting, interventional procedures, and multidisciplinary team meeting attendance, although 62% of programmes noted an increase in service provision. Less in-person feedback was reported with in-person training still deemed necessary for practical skills. The Royal College of Radiologists Junior Radiologists Forum webinars were well received by all trainees with continuation of the series recommended. CONCLUSION: The COVID-19 pandemic has had a clear impact on many areas of radiology training in the UK. Early strategies have been adopted to mitigate the challenges faced by trainees and opportunities for future improvement are highlighted.


Subject(s)
COVID-19/prevention & control , Clinical Competence/statistics & numerical data , Education, Distance/methods , Education, Medical, Graduate/methods , Radiologists/statistics & numerical data , Radiology/education , Humans , Pandemics , SARS-CoV-2 , Surveys and Questionnaires , United Kingdom
6.
Clin Radiol ; 76(6): 443-446, 2021 06.
Article in English | MEDLINE | ID: covidwho-1144570

ABSTRACT

AIM: To assess, via a survey of UK radiological departments, if the COVID-19 pandemic led to a change in radiological reporting undertaken in a home environment with appropriate IT support. MATERIALS AND METHODS: All imaging departments in the UK were contacted and asked about the provision of home reporting and IT support before and after the first wave of the pandemic. RESULTS: One hundred and thirty-seven of the 217 departments contacted replied, producing a response rate of 61%. There was a 147% increase in the provision of remote access viewing and reporting platforms during the pandemic. Although 578 consultants had access to a viewing platform pre-pandemic, this had increased to 1,431 during the course of the first wave. CONCLUSION: This survey represents work undertaken by UK NHS Trusts in co-ordinating and providing increased home-reporting facilities to UK radiologists during the first wave of this global pandemic. The impact of these facilities has been shown to allow more than just the provision of reporting of both elective and emergency imaging and provides additional flexibility in how UK radiologists can help support and provide services. This is a good start, but there are potential problems that now need to be overcome.


Subject(s)
COVID-19/epidemiology , Pandemics , Radiology Department, Hospital/organization & administration , Teleworking , Health Care Surveys , Humans , SARS-CoV-2 , United Kingdom/epidemiology
7.
Clin Radiol ; 75(9): 705-708, 2020 09.
Article in English | MEDLINE | ID: covidwho-612669

ABSTRACT

AIM: To report on a snap audit of all departments in the UK as to the value of preoperative thoracic imaging, preferably computed tomography (CT), of patients undergoing any surgery to assess for changes consistent with COVID-19 preoperatively. MATERIALS AND METHODS: All Imaging departments in the UK were contacted and asked to record the number of preoperative CT examinations performed in patients being considered for both emergency and elective surgical intervention over a 5-day period in May 2020. RESULTS: Forty-seven percent of departments replied with data provided on >820 patients. Nineteen percent of additional preoperative CT was in patients undergoing elective intervention and 81% in patients presenting with surgical abdominal pain. There was a high rate of false positives in patients who tested negative for COVID-19, producing a sensitivity for thoracic CT of 68.4%. CONCLUSION: This UK-wide audit demonstrates that a large number of additional thoracic imaging examinations over a 5-day period were performed with a low sensitivity for the identification of COVID-19 in this preoperative group of patients. Given these findings, it is difficult to justify this additional examination in this group of patients.


Subject(s)
Betacoronavirus , Coronavirus Infections/diagnostic imaging , Medical Audit/methods , Pneumonia, Viral/diagnostic imaging , Preoperative Care/methods , Surgical Procedures, Operative , Tomography, X-Ray Computed/methods , COVID-19 , Humans , Lung/diagnostic imaging , Medical Audit/statistics & numerical data , Pandemics , Prospective Studies , Radiography, Thoracic , Reproducibility of Results , SARS-CoV-2 , Sensitivity and Specificity , United Kingdom
8.
Clin Radiol ; 75(8): 592-598, 2020 08.
Article in English | MEDLINE | ID: covidwho-591561

ABSTRACT

AIM: To evaluate the diagnostic utility of additional whole-chest computed tomography (CT) in identifying otherwise unheralded COVID-19 lung disease as part of an acute abdominal pain CT imaging pathway in response to the COVID-19 pandemic. MATERIALS AND METHODS: Consecutive patients (n=172) who underwent additional whole-chest CT via a COVID-19 acute abdominal pain CT imaging pathway between 27 March and 3 May 2020 were evaluated in this retrospective single-centre study. Chest CT examinations were graded as non-COVID-19, indeterminate for, or classic/probable for COVID-19. CT examinations in the latter two categories were further divided into one of three anatomical distributions (lung base, limited chest [below carina], whole chest [above carina]) based on location of findings. Reverse transcriptase-polymerase chain reaction (RT-PCR) results and clinical features of COVID-19 were assessed to determine if COVID-19 was clinically suspected at the time of CT referral. RESULTS: Twenty-seven of the 172 (15.7%) patients had CT features potentially indicative of COVID-19 pneumonia, 6/27 (3.5%) demonstrating a classic/probable pattern and 21/27 (12.2%) demonstrating an indeterminate pattern. After correlation with clinical features and RT-PCR 8/172 (4.7%) were defined as COVID-19 positive, of which only 1/172 (0.6%) was clinically unsuspected of COVID-19 at the time of CT referral. All COVID-19 positive cases could be identified on review of the lung base alone. CONCLUSION: Whole-chest CT as part of an acute abdominal pain CT imaging pathway has a very low diagnostic yield for our cohort of patients. All COVID-19-positive patients in our cohort were identified on review of the lung bases on the abdominal CT and this offers an alternative imaging approach in this patient group.


Subject(s)
Abdominal Pain/etiology , Betacoronavirus , Coronavirus Infections/complications , Coronavirus Infections/diagnostic imaging , Pneumonia, Viral/complications , Pneumonia, Viral/diagnostic imaging , Radiography, Thoracic/methods , Tomography, X-Ray Computed/methods , Acute Disease , COVID-19 , Female , Humans , Male , Middle Aged , Pandemics , Retrospective Studies , SARS-CoV-2
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