Effect of Inpatient Medication-Assisted Therapy on Against-Medical-Advice Discharge and Readmission Rates.

BACKGROUND: Patients who present to the hospital for infectious complications of intravenous opioid use are at high risk for against-medical-advice discharge and readmissions. The role of medication-assisted treatment for inpatients is not clear. We aimed to assess outcomes prior to and after rollout of an inpatient buprenorphine-based opioid use disorder protocol, as well as to assess outcomes in general for medication-assisted therapy. METHODS: This was a retrospective observational cohort study at our community hospital in New Hampshire. The medical record was searched for inpatients with a complication of intravenous opioid use. We searched for admissions 11 months prior to and after the November 2018 buprenorphine protocol rollout. RESULTS: Rates of medication-assisted therapy usage and buprenorphine linkage increased significantly after protocol rollout. Rates of against-medical-advice discharge did not decrease after protocol rollout, nor did readmissions. However, when evaluating the entire group of patients regardless of date of presentation or protocol use, against-medical-advice discharge rates were substantially lower for patients receiving medication-assisted therapy compared with those receiving supportive care only (30.0% vs 59.6%). Readmissions rates were lower for patients who were discharged with any form of ongoing medication-assisted therapy compared with those who were not (30-day all-cause readmissions 18.8% vs 35.1%; 30-day opioid-related readmissions 10.1% vs 29.9%; 90-day all-cause readmissions 27.3% vs 42.7%; 90-day opioid-related readmissions 15.1% vs 33.3%). CONCLUSIONS: There is a strong association between medication-assisted therapy and reduced against-medical-advice discharge rates. Additionally, maintenance medication-assisted therapy at time of discharge is strongly associated with reduced readmissions rates.

Outcomes from a Whole-Systems Ayurvedic Medicine and Yoga Therapy Treatment for Obesity Pilot Study.

OBJECTIVES: To determine the feasibility and acceptability of an Ayurveda/Yoga intervention for weight loss, using dual-diagnosis inclusion criteria, dual-paradigm outcomes, and a semistandardized protocol with tailoring according to the Ayurvedic constitution/imbalance profile of each participant. DESIGN: Seventeen participants enrolled in a weekly intervention for 3 months. Outcome measurements were performed at baseline, postintervention, and 3 and 6 months follow-up. SETTING: The intervention was conducted through the University of Arizona, Department of Family and Community Medicine from April through December 2012. SUBJECTS: Participants included 2 men and 15 women recruited from the community of Tucson, AZ using flyers and hospital message boards. Seventeen enrolled and 12 participants provided complete follow-up data. INTERVENTION: Participants met with an Ayurvedic practitioner twice monthly (six times) and followed semistandardized dietary guidelines with individual tailoring to address relevant psychophysiological imbalances obstructing weight loss and a standardized protocol of therapeutic yoga classes three times weekly with recommended home practice of two to four additional sessions. OUTCOME MEASURES: Primary outcome was weight loss. Other biomedical outcomes included body mass index, body fat percentage, waist and hip circumference, waist to hip ratio, and blood pressure. Unique instruments were designed to collect data on outcomes associated with the Ayurvedic medical paradigm, including dietary changes by food qualities, mood/affect, relationships, and changes in Ayurvedic imbalance profiles. RESULTS: Participants lost an average of 3.5 kg during the 3-month intervention. Weight loss at 3 and 6 months postintervention increased to an average of 5.6 kg and 5.9 kg, respectively. Participants who lost 3% of their body weight during the 12 week intervention, lost on average an additional 3% during the follow-up period. Psychosocial outcomes also improved. No additional services were provided to participants during the follow-up period. CONCLUSIONS: A whole-systems Ayurvedic medicine and Yoga therapy approach provides a feasible promising noninvasive low-cost alternative to traditional weight loss interventions with potential added benefits associated with sustainable holistic lifestyle modification and positive psychosocial changes.

Convergent Points for Conventional Medicine and Whole Systems Research: A User's Guide.

CONTEXT: Value-based health care has emerged as a manifestation of the conventional medicine community's awareness of the overlapping needs to both better incorporate patient centeredness into practice and research paradigms and further develop a systemic approach to cost reduction. BACKGROUND: The origins of the whole systems research (WSR) movement date to the late 1990s, when the U.S. Congress legislated appropriation of funds to stimulate the U.S. National Institutes of Health to evaluate popular traditional, complementary, and integrative medicine (TCIM) practices. Questions immediately arose over how well these forms of practice could be measured through standard randomized controlled trials, and the WSR community began to articulate and adapt innovative methodologies for evaluating TCIM interventions. DISCUSSION: This column explores the potential impact of WSR methods and exemplars on the clinical practice and research communities seeking to successfully implement and measure the complexities of value-based health care. Four potentially cross-talking themes are specifically discussed: complex behaviorally focused interventions, patient-centered outcomes, team-based care, and resilience and well-being. CONCLUSION: The time is ripe for clinicians and investigators to capitalize on methodologies, exemplars, and learnings from the WSR literature toward improving care, developing more robust research strategies, and furthering the dialogue between the TCIM and conventional medicine communities.

Whole Systems Research Methods in Health Care: A Scoping Review.

OBJECTIVES: This scoping review evaluates two decades of methodological advances made by "whole systems research" (WSR) pioneers in the fields of traditional, complementary, and integrative medicine (TCIM). Rooted in critiques of the classical randomized controlled trial (RCT)'s suitability for evaluating holistic, complex TCIM interventions, WSR centralizes the principle of "model validity," representing a "fit" between research design and therapeutic paradigm. DESIGN: In consultation with field experts, 41 clinical research exemplars were selected for review from across 13 TCIM disciplines, with the aim of mapping the range and methodological characteristics of WSR studies. Using an analytic charting approach, these studies' primary and secondary features are characterized with reference to three focal areas: research method, intervention design, and outcome assessment. RESULTS: The reviewed WSR exemplars investigate a wide range of multimodal and multicomponent TCIM interventions, typified by wellness-geared, multitarget, and multimorbid therapeutic aims. Most studies include a behavioral focus, at times in multidisciplinary or team-based contexts. Treatments are variously individualized, often with reference to "dual" (biomedical and paradigm-specific) diagnoses. Prospective and retrospective study designs substantially reflect established biomedical research methods. Pragmatic, randomized, open label comparative effectiveness designs with "usual care" comparators are most widely used, at times with factorial treatment arms. Only two studies adopt a double-blind, placebo-controlled RCT format. Some cohort-based controlled trials engage nonrandomized allocation strategies (e.g., matched controls, preference-based assignment, and minimization); other key designs include single-cohort pre-post studies, modified n-of-1 series, case series, case report, and ethnography. Mixed methods designs (i.e., qualitative research and economic evaluations) are evident in about one-third of exemplars. Primary and secondary outcomes are predominantly assessed, at multiple intervals, through patient-reported measures for symptom severity, quality of life/wellness, and/or treatment satisfaction; some studies concurrently evaluate objective outcomes. CONCLUSIONS: Aligned with trends emphasizing "fit-for-purpose" research designs to study the "real-world" effectiveness of complex, personalized clinical interventions, WSR has emerged as a maturing scholarly discipline. The field is distinguished by its patient-centered salutogenic focus and engagement with nonbiomedical diagnostic and treatment frameworks. The rigorous pursuit of model validity may be further advanced by emphasizing complex analytic models, paradigm-specific outcome assessment, inter-rater reliability, and ethnographically informed designs. Policy makers and funders seeking to support best practices in TCIM research may refer to this review as a key resource.

Yoga Therapy Research: A Whole-Systems Perspective on Comparative Effectiveness and Patient-Centered Outcomes.

For the yoga research community to capitalize on its current momentum, it is critical to consider certain developments in research theory and innovative methodologies. The concept of model validity must be incorporated in yoga therapy research so that explanatory constructs employed and outcome measures chosen reflect the principles of traditional yogic science. Focusing on effectiveness research will ensure maximum generalizability of study results and reflect real-world therapy delivery settings, thereby increasing the relevance of outcomes. Whole systems of healing require research methodologies that address complex relationships between multi-target therapies with multiple potential treatment results. Complex, dynamic systems theory provides the theoretical and methodological innovations necessary to design studies, choose outcomes, and analyze data in a way that can account for charting complex, cyclical, therapeutic trajectories across time. Emphasizing patient-centered outcomes is aligned with the patent-oriented and tailored natured of yoga therapy delivery. Increasing the quality and quantity of comparative effectiveness research to analyze the harms and benefits of contrasting therapies can provide an infrastructure for designing studies that can have significant practical impact. The creation of practice-based research networks within the yoga research community will incentivize links between mainstream clinical researchers and yoga therapy delivery settings, ultimately developing collaborative networks. Yoga therapy centers can facilitate patient recruitment for studies and inform standards for yoga researchers. Collaborative efforts between the yoga and ayurvedic research communities will streamline efforts, solidify expertise, cross-pollinate theoretical and methodological innovation, and consolidate efforts to secure research funding and increase publication and dissemination of study findings.

Why Ayurvedic Yoga Therapists and Why Now?

IAYT has paved the way for yoga therapy as a healing profession to grow and develop its mission to deliver optimal therapeutics via individual sessions and tailored group classes. For the past five years, the National Ayurvedic Medical Association (NAMA) has been working behind the scenes to consider the value and definition of an ayurvedic yoga therapist (AYT) professional designation within the yoga therapy discipline. The AYT designation would complement the current standards for yoga therapists that have been published by IAYT. The purpose of this paper is to discuss (1) why the AYT designation is important; (2) how it supports and expands on IAYT's mission; and (3) why now is the appropriate time to develop competencies, standards, and a scope of practice for ayurvedic yoga therapy.

A Pilot Feasibility Study of Whole-systems Ayurvedic Medicine and Yoga Therapy for Weight Loss.

OBJECTIVE: To develop and test the feasibility of a whole-systems lifestyle intervention for obesity treatment based on the practices of Ayurvedic medicine/ Yoga therapy. DESIGN: A pre-post weight loss intervention pilot study using conventional and Ayurvedic diagnosis inclusion criteria, tailored treatment within a standardized treatment algorithm, and standardized data collection instruments for collecting Ayurvedic outcomes. PARTICIPANTS: A convenience sample of overweight/obese adult community members from Tucson, Arizona interested in a "holistic weight loss program" and meeting predetermined inclusion/exclusion criteria. INTERVENTION: A comprehensive diet, activity, and lifestyle modification program based on principles of Ayurvedic medicine/yoga therapy with significant self-monitoring of lifestyle behaviors. The 3-month program was designed to change eating and activity patterns and to improve self-efficacy, quality of life, well-being, vitality, and self-awareness around food choices, stress management, and barriers to weight loss. PRIMARY OUTCOME MEASURES: Changes in body weight, body mass index; body fat percentage, fat/lean mass, waist/hip circumference and ratio, and blood pressure. SECONDARY OUTCOME MEASURES: Diet and exercise self-efficacy scales; perceived stress scale; visual analog scales (VAS) of energy, appetite, stress, quality of life, well-being, and program satisfaction at all time points. RESULTS: Twenty-two adults attended an in-person Ayurvedic screening; 17 initiated the intervention, and 12 completed the 3-month intervention. Twelve completed follow-up at 6 months and 11 completed follow-up at 9 months. Mean weight loss at 3 months was 3.54 kg (SD 4.76); 6 months: 4.63 kg, (SD 6.23) and 9 months: 5.9 kg (SD 8.52). Self-report of program satisfaction was more than 90% at all time points. CONCLUSIONS: An Ayurveda-/yoga-based lifestyle modification program is an acceptable and feasible approach to weight management. Data collection, including self-monitoring and conventional and Ayurvedic outcomes, did not unduly burden participants, with attrition similar to that of other weight loss studies.

Narrative review of yoga intervention clinical trials including weight-related outcomes.

CONTEXT: Medical authorities have identified obesity as a causal factor in the development of diabetes, hypertension, and cardiovascular disease (CVD), and more broadly, of metabolic syndrome/insulin resistance syndrome. To provide solutions that can modify this risk factor, researchers need to identify methods of effective risk reduction and primary prevention of obesity. Research on the effectiveness of yoga as a treatment for obesity is limited, and studies vary in overall quality and methodological rigor. OBJECTIVE: This narrative review assessed the quantity and quality of clinical trials of yoga as an intervention for weight loss or as a means of risk reduction or treatment for obesity and diseases in which obesity is a causal factor. This review summarized the studies' research designs and evaluated the efficacy of yoga for weight loss via the current evidence base. DESIGN: The research team evaluated published studies to determine the appropriateness of research designs, comparability of programs' intervention elements, and standardization of outcome measures. The research team's literature search used the key terms yoga and obesity or yoga and weight loss in three primary medical-literature databases (PubMed, PsychInfo, and Web of Science). The study excluded clinical trials with no quantitative obesity related measure. Extracted data included each study's (1) design; (2) setting and population; (3) nature, duration, and frequency of interventions; (4) comparison groups; (5) recruitment strategies; (6) outcome measures; (7) data analysis and presentation; and (8) results and conclusions. The research team developed an overall evaluation parameter to compare disparate trials. OUTCOME MEASURES: The research team reviewed each study to determine its key features, each worth a specified number of points, with a maximum total of 20 points. The features included a study's (1) duration, (2) frequency of yoga practice, (3) intensity of (length of) each practice, (4) number of yogic elements, (5) inclusion of dietary modification, (6) inclusion of a residential component, (7) the number of weight-related outcome measures, and (8) a discussion of the details of the yogic elements. RESULTS: Overall, therapeutic yoga programs are frequently effective in promoting weight loss and/or improvements in body composition. The effectiveness of yoga for weight loss is related to the following key features: (1) an increased frequency of practice; (2) a longer intervention duration (3) a yogic dietary component; (4) a residential component; (5) the comprehensive inclusion of yogic components; (5) and a home-practice component. CONCLUSIONS: Yoga appears to be an appropriate and potentially successful intervention for weight maintenance, prevention of obesity, and risk reduction for diseases in which obesity plays a significant causal role.

A complex, nonlinear dynamic systems perspective on Ayurveda and Ayurvedic research.

The fields of complexity theory and nonlinear dynamic systems (NDS) are relevant for analyzing the theory and practice of Ayurvedic medicine from a Western scientific perspective. Ayurvedic definitions of health map clearly onto the tenets of both systems and complexity theory and focus primarily on the preservation of organismic equanimity. Health care research informed by NDS and complexity theory would prioritize (1) ascertaining patterns reflected in whole systems as opposed to isolating components; (2) relationships and dynamic interaction rather than static end-points; (3) transitions, change and cumulative effects, consistent with delivery of therapeutic packages in the reality of the clinical setting; and (4) simultaneously exploring both local and global levels of healing phenomena. NDS and complexity theory are useful in examining nonlinear transitions between states of health and illness; the qualitative nature of shifts in health status; and looking at emergent properties and behaviors stemming from interactions between organismic and environmental systems. Complexity and NDS theory also demonstrate promise for enhancing the suitability of research strategies applied to Ayurvedic medicine through utilizing core concepts such as initial conditions, emergent properties, fractal patterns, and critical fluctuations. In the Ayurvedic paradigm, multiple scales and their interactions are addressed simultaneously, necessitating data collection on change patterns that occur on continuums of both time and space, and are viewed as complementary rather than isolated and discrete. Serious consideration of Ayurvedic clinical understandings will necessitate new measurement options that can account for the relevance of both context and environmental factors, in terms of local biology and the processual features of the clinical encounter. Relevant research design issues will need to address clinical tailoring strategies and provide mechanisms for mapping patterns of change that account for the contiguous, self-replicating, cumulative, and synergistic theories associated with successful Ayurvedic treatment approaches.