Determinants of implementation for group medical visits for patients with chronic pain: a systematic review.

BACKGROUND: Despite the critical need for comprehensive and effective chronic pain care, delivery of such care remains challenging. Group medical visits (GMVs) offer an innovative and efficient model for providing comprehensive care for patients with chronic pain. The purpose of this systematic review was to identify barriers and facilitators (determinants) to implementing GMVs for adult patients with chronic pain. METHODS: The review included peer-reviewed studies reporting findings on implementation of GMVs for chronic pain, inclusive of all study designs. Pubmed, EMBASE, Web of Science, and Cochrane Library were searched. Studies of individual appointments or group therapy were excluded. The Mixed Methods Appraisal Tool was used to determine risk of bias. Data related to implementation determinants were extracted independently by two reviewers. Data synthesis was guided by the updated Consolidated Framework for Implementation Research. RESULTS: Thirty-three articles reporting on 25 studies met criteria for inclusion and included qualitative observational (n = 8), randomized controlled trial (n = 6), quantitative non-randomized (n = 9), quantitative descriptive (n = 3), and mixed methods designs (n = 7). The studies included in this review included a total of 2364 participants. Quality ratings were mixed, with qualitative articles receiving the highest quality ratings. Common multi-level determinants included the relative advantage of GMVs for chronic pain over other available models, the capability and motivation of clinicians, the cost of GMVs to patients and the health system, the need and opportunity of patients, the availability of resources and relational connections supporting recruitment and referral to GMVs within the clinic setting, and financing and policies within the outer setting. CONCLUSIONS: Multi-level factors determine the implementation of GMVs for chronic pain. Future research is needed to investigate these determinants more thoroughly and to develop and test implementation strategies addressing these determinants to promote the scale-up of GMVs for patients with chronic pain. TRIAL REGISTRATION: This systematic review was registered with PROSPERO 2021 CRD42021231310 .

Race-Based Differences in the Response to a Mindfulness Based Integrative Medical Group Visit Intervention for Chronic Pain.

Background: Chronic pain is one of the most common drivers of healthcare utilization and a marked domain for health disparities, as African American/Black populations experience high rates of chronic pain. Integrative Medical Group Visits (IMGV) combine mindfulness techniques, evidence-based integrative medicine, and medical group visits. In a parent randomized controlled trial, this approach was tested as an adjunct treatment in a diverse, medically underserved population with chronic pain and depression. Objective: To determine race-based heterogeneity in the effects of a mindfulness based treatment for chronic pain. Methods: This secondary analysis of the parent trial assessed heterogeneity of treatment effects along racialized identity in terms of primary patient-reported pain outcomes in a racially diverse sample suffering from chronic pain and depression. The analytic approach examined comorbidities and sociodemographics between racialized groups. RMANOVAs examined trajectories in pain outcomes (average pain, pain severity, and pain interference) over three timepoints (baseline, 9, and 21 weeks) between participants identifying as African American/Black (n = 90) vs White (n = 29) across both intervention and control conditions. Results: At baseline, African American/Black participants had higher pain severity and had significantly different age, work status, and comorbidity profiles. RMANOVA models also identified significant race-based differences in the response to the parent IMGV intervention. There was reduced pain severity in African American/Black subjects in the IMGV condition from baseline to 9 weeks. This change was not observed in White participants over this time period. However, there was a reduction in pain severity in White participants over the subsequent interval from 9 to 21 week where IMGV had no significant effect in African American/Black subjects during this latter time period. Conclusion: Interactions between pain and racialization require further investigation to understand how race-based heterogeneity in the response to integrative medicine treatments for chronic pain contribute to the broader landscape of health inequity.

Effects of live-online, group mindfulness training on opioid use and anxiety during buprenorphine treatment: A comparative effectiveness RCT.

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

Integrative medical group visits for patients with chronic pain: results of a pilot single-site hybrid implementation-effectiveness feasibility study.

Background: Approximately 20% of adults in the United States experience chronic pain. Integrative Medical Group Visit (IMGV) offers an innovative approach to chronic pain management through training in mindfulness, nutrition, and other mind-body techniques combined with peer support. To date, there are no studies on IMGV implementation, despite its promise as a feasible non-pharmacological intervention for chronic pain management. In this study, we assessed the feasibility of implementing IMGV and assessing its effectiveness for chronic pain. Methods: Implementation Mapping was used to develop and evaluate implementation strategies for IMGV. Strategies included disseminating educational materials, conducting ongoing training, and conducting educational meetings. IMGV was delivered by three healthcare providers: an allopathic physician, registered yoga teacher, and naturopathic physician. The effectiveness of IMGV on patient health outcomes was assessed through qualitative interviews and a Patient-Reported Outcomes Scale (PROMIS-29). Provider perspectives of acceptability, appropriateness, and feasibility were assessed through periodic reflections (group interviews reflecting on the process of implementation) and field notes. Paired t-tests were used to assess changes between scores at baseline and post intervention. Qualitative data were coded by three experienced qualitative researchers using thematic content analysis. Results: Of the initial 16 patients enrolled in research, 12 completed at least two sessions of the IMGV. Other than fatigue, there was no statistically significant difference between the pre- and post-scores. Patients reported high satisfaction with IMGV, noting the development of new skills for self-care and the supportive community of peers. Themes from patient interviews and periodic reflections included the feasibility of virtual delivery, patient perspectives on acceptability, provider perspectives of feasibility and acceptability, ease of recruitment, complexity of referral and scheduling process, balancing medical check-in with group engagement, and nursing staff availability. Conclusions: IMGV was feasible, acceptable, and effective from the perspectives of patients and providers. Although statistically significant differences were not observed for most PROMIS measures, qualitative results suggested that participants experienced increased social support and increased pain coping skills. Providers found implementation strategies effective, except for engaging nurses, due to staff being overwhelmed from the pandemic. Lessons learned from this pilot study can inform future research on implementation of IMGV.

Pilot Observational Study of Patient Reported Outcome Measures for Long COVID Patients in Virtual Integrative Medical Group Visits.

Background: Long COVID is a common, debilitating post-infectious illness for which effective management is unknown. Integrative Medical Group Visits (IMGV) are effective interventions for chronic conditions and could benefit Long COVID patients. More information is needed regarding existing patient reported outcome measures (PROMs) to evaluate efficacy of IMGV for Long COVID. Objective: This study assessed the feasibility of specific PROMS to evaluate IMGVs for Long COVID. Findings will inform future efficacy trials. Methods: The Perceived Stress Scale (PSS-10), General Anxiety Disorder two-question tool (GAD-2), Fibromyalgia Symptom Severity scale (SSS), and Measure Yourself Medical Outcome Profile (MYMOP®) were collected pre- and post-group by teleconferencing platform or telephone and compared using paired t-tests. Patients were recruited from a Long COVID specialty clinic where they participated in 2-hour - 8 weekly IMGV sessions online. Results: Twenty-seven participants enrolled and completed pre-group surveys. Fourteen participants were reachable by phone post-group and completed all pre and post PROMs (78.6% female, 71.4% non-Hispanic White, mean age 49). MYMOP® primary symptomatology was fatigue, shortness of breath and "brain fog". Symptoms decreased in interference when compared to pre-group levels (mean difference -1.3 [95% CI-2.2, -.5]). PSS scores decreased (-3.4 [95% CI -5.8, -1.1]), and GAD-2 mean difference was -1.43 (95% CI -3.12, .26). There were no changes in SSS scores of fatigue (-.21 [95% CI -.68,0.25]), waking unrefreshed (.00 [95%CI -.32, -.32]), or trouble thinking (-.21 [95% CI -.78,0.35]). Conclusion: All PROMs were feasible to administer via teleconferencing platform or telephone. The PSS, GAD-2 and MYMOP® are promising PROMs to track Long COVID symptomatology among IMGV participants. The SSS, while feasible to administer, did not change compared to baseline. Larger, controlled studies are needed to determine the efficacy of virtual IMGVs to address the needs of this large and growing population.

Effectiveness of an Immersive Telemedicine Platform for Delivering Diabetes Medical Group Visits for African American, Black and Hispanic, or Latina Women With Uncontrolled Diabetes: The Women in Control 2.0 Noninferiority Randomized Clinical Trial.

BACKGROUND: Medically underserved people with type 2 diabetes mellitus face limited access to group-based diabetes care, placing them at risk for poor disease control and complications. Immersive technology and telemedicine solutions could bridge this gap. OBJECTIVE: The purpose of this study was to compare the effectiveness of diabetes medical group visits (DMGVs) delivered in an immersive telemedicine platform versus an in-person (IP) setting and establish the noninferiority of the technology-enabled approach for changes in hemoglobin A1c (HbA1c) and physical activity (measured in metabolic equivalent of task [MET]) at 6 months. METHODS: This study is a noninferiority randomized controlled trial conducted from February 2017 to December 2019 at an urban safety net health system and community health center. We enrolled adult women (aged ≥18 years) who self-reported African American or Black race or Hispanic or Latina ethnicity and had type 2 diabetes mellitus and HbA1c ≥8%. Participants attended 8 weekly DMGVs, which included diabetes self-management education, peer support, and clinician counseling using a culturally adapted curriculum in English or Spanish. In-person participants convened in clinical settings, while virtual world (VW) participants met remotely via an avatar-driven, 3D VW linked to video teleconferencing. Follow-up occurred 6 months post enrollment. Primary outcomes were mean changes in HbA1c and physical activity at 6 months, with noninferiority margins of 0.7% and 12 MET-hours, respectively. Secondary outcomes included changes in diabetes distress and depressive symptoms. RESULTS: Of 309 female participants (mean age 55, SD 10.6 years; n=195, 63% African American or Black; n=105, 34% Hispanic or Latina; n=151 IP; and n=158 in VW), 207 (67%) met per-protocol criteria. In the intention-to-treat analysis, we confirmed noninferiority for primary outcomes. We found similar improvements in mean HbA1c by group at 6 months (IP: -0.8%, SD 1.9%; VW: -0.5%, SD 1.8%; mean difference 0.3, 97.5% CI -∞ to 0.3; P<.001). However, there were no detectable improvements in physical activity (IP: -6.5, SD 43.6; VW: -9.6, SD 44.8 MET-hours; mean difference -3.1, 97.5% CI -6.9 to ∞; P=.02). The proportion of participants with significant diabetes distress and depressive symptoms at 6 months decreased in both groups. CONCLUSIONS: In this noninferiority randomized controlled trial, immersive telemedicine was a noninferior platform for delivering diabetes care, eliciting comparable glycemic control improvement, and enhancing patient engagement, compared to IP DMGVs. TRIAL REGISTRATION: ClinicalTrials.gov NCT02726425; https://clinicaltrials.gov/ct2/show/NCT02726425.

Functional neurological disorder is a feminist issue.

Functional neurological disorder (FND) is a common and disabling disorder, often misunderstood by clinicians. Although viewed sceptically by some, FND is a diagnosis that can be made accurately, based on positive clinical signs, with clinical features that have remained stable for over 100 years. Despite some progress in the last decade, people with FND continue to suffer subtle and overt forms of discrimination by clinicians, researchers and the public. There is abundant evidence that disorders perceived as primarily affecting women are neglected in healthcare and medical research, and the course of FND mirrors this neglect. We outline the reasons why FND is a feminist issue, incorporating historical and contemporary clinical, research and social perspectives. We call for parity for FND in medical education, research and clinical service development so that people affected by FND can receive the care they need.

A Systematic Review of the Adherence to Home-Practice Meditation Exercises in Patients with Chronic Pain.

Mindfulness-, compassion-, and acceptance-based (i.e., "third wave") psychotherapies are effective for treating chronic pain conditions. Many of these programs require that patients engage in the systematic home practice of meditation experiences so they can develop meditation skills. This systematic review aimed at evaluating the frequency, duration, and effects of home practice in patients with chronic pain undergoing a "third wave" psychotherapy. A comprehensive database search for quantitative studies was conducted in PubMed, Embase, and Web of Sciences Core Collection; 31 studies fulfilled the inclusion criteria. The reviewed studies tended to indicate a pattern of moderately frequent practice (around four days/week), with very high variability in terms of time invested; most studies observed significant associations between the amount of practice and positive health outcomes. Mindfulness-Based Stress Reduction and Mindfulness-Based Cognitive Therapy were the most common interventions and presented low levels of adherence to home practice (39.6% of the recommended time). Some studies were conducted on samples of adolescents, who practiced very few minutes, and a few tested eHealth interventions with heterogeneous adherence levels. In conclusion, some adaptations may be required so that patients with chronic pain can engage more easily and, thus, effectively in home meditation practices.

Mechanisms of mindfulness in patients with migraine: Results of a qualitative study.

OBJECTIVE: To understand the mechanisms of mindfulness' impact on migraine. BACKGROUND: Promising mindfulness research demonstrates potential benefit in migraine, but no data-driven model exists from the lived experiences of patients that explains the mechanisms of mindfulness in migraine. METHODS: Semi-structured qualitative interviews were conducted with adults with migraine who participated in two mindfulness-based stress reduction (MBSR) clinical trials (n = 43). Interviews were audio-recorded, transcribed, and summarized into a framework matrix with development of a master codebook. Constructivist grounded theory approach was used to identify themes/subthemes. RESULTS: Participants who learned mindfulness techniques through MBSR experienced altered pain perception, altered response to migraine attacks and disease, increased awareness of external and internal experiences, improved overall well-being, and group benefits. Mindfulness resulted in earlier stress-body awareness and increased interoceptive awareness resulting in earlier attack recognition, leading to earlier and more effective management. Interictal factors of self-blame, guilt, and stigma decreased while migraine acceptance, hope, empowerment, self-efficacy, and self-compassion increased. Improved emotion regulation resulted in decreased fear of migraine, pain catastrophizing, anticipatory anxiety, and pain reactivity. Although taught as prevention, mindfulness was used both acutely and prophylactically. We created a conceptual model hypothesizing that MBSR skills led to an infusion of mindfulness in daily life, resulting in altered pain perception and experience, ultimately leading to improvement in overall well-being, which may positively feed back to the infusion of mindfulness in daily life. The therapeutic benefit of learning mindfulness in a group setting may moderate these effects. CONCLUSIONS: This study identified several new potential mechanisms of mindfulness' effect on migraine. After learning MBSR skills, participants reported altered pain and migraine perception and experiences. Increased stress-body and interoceptive awareness resulted in earlier migraine awareness and treatment. Mindfulness may target important interictal factors that affect disease burden such as fear of migraine, pain catastrophizing, and anticipatory anxiety. This is the first data-driven study to help elucidate the mechanisms of mindfulness on migraine from patient voices and can help direct future research endeavors.

Lessons Learned from Clinicians in a Federally Qualified Health Center: Steps Toward Eliminating Burnout.

Background: Burnout continues to impact health care workers and its effect takes a toll on their lives and wellbeing, especially in primary care. Relatively few studies have focused specifically on the perspective of clinicians in Federally Qualified Health Centers (FQHCs), which offer crucial, preventative health care services to vulnerable and underserved patient populations. Objective: To examine the perspectives of clinicians working at an FQHC in the Northeast United States after the implementation of a year-long wellness initiative. Design: A qualitative analysis of clinician's discussion during focus groups conducted after the wellness initiative. Subjects and Setting/Location: A total of 28 clinicians (primary care physicians and nurse practitioners) in an FQHC in the Northeast United States. Interventions: A one-year wellness initiative with programs and activities designed to bolster wellness. Outcome Measures: Analyzed NVIVO-coded transcripts of focus group discussion to generate codes and used modified grounded theory to extrapolate meaningful themes. Results: Five key themes emerged from the qualitative analysis: (1) clinicians often felt burdened by their workload and personally responsible when they were not able to provide optimal care to patients; (2) burnout was exacerbated by systemic problems at the FQHC; (3) medical assistants, medical scribes, schedulers, and other support staff played a crucial role in the wellness of the entire team; (4) perceived differences in priorities between administration and health care workers may have contributed to burnout; and (5) a communicative and stable team helped clinicians effectively care for their patients. Conclusions: Clinician burnout is a complex problem at FQHCs with many root causes. Addressing burnout and improving clinician wellness at FQHCs will require a multifaceted approach encompassing systemic, team, and individual components. The perspectives from the clinicians at our FQHC may inform wellness strategies for other safety net, clinical institutions in the primary care setting.

Our Whole Lives for Hypertension and Cardiac Risk Factors-Combining a Teaching Kitchen Group Visit With a Web-Based Platform: Feasibility Trial.

BACKGROUND: Hypertension (HTN) affects millions of Americans. Our Whole Lives: an eHealth toolkit for Hypertension and Cardiac Risk Factors (OWL-H) is an eHealth platform that teaches evidence-based lifestyle strategies, such mindfulness and cooking skills, to improve self-management of HTN. OBJECTIVE: The primary goal of this pilot study was to evaluate the feasibility of OWL-H combined with teaching kitchen medical group visits (TKMGVs) in a low-income population of participants with HTN. METHODS: We conducted a pre-post 8-week study to assess the feasibility of a hybrid program (a web-based 9-module self-management program, which includes mindfulness and Mediterranean and Dietary Approaches to Stop Hypertension diet) accompanied by 3 in-person TKMGVs among patients with HTN. Data including demographics, platform use, and satisfaction after using OWL-H were examined. Outcome data collected at baseline and 8 weeks included the Mediterranean Diet Questionnaire, Hypertension Self-Care Profile Self-Efficacy Instrument, Blood Pressure Knowledge Questionnaire, and the number of self-reported blood pressure readings. For the statistical analysis, we used descriptive statistics, paired sample t tests (1-tailed), and qualitative methods. RESULTS: Of the 25 enrolled participants, 22 (88%) participants completed the study. Participants' average age was 57 (SD 12.1) years, and 46% (11/24) of them reported a household income

Integrative Approaches to Pediatric Chronic Pain in an Urban Safety-Net Hospital: Cost Savings, Clinical Benefits, and Safety.

Purpose: Chronic pain experienced by children and adolescents represents a significant burden in terms of health, quality of life, and economic costs to U.S. families. In 2015, the Boston Medical Center (BMC) Interdisciplinary Pain Clinic initiated an Integrative Medicine (IM) team model to address chronic pain in children. Team members included a pediatrician, child psychologist, physical therapist, acupuncturist, and massage therapist. Children were referred to the pain clinic from primary care and specialty services within BMC, the largest safety-net hospital in the northeastern United States. For this observational assessment, consent and assent were obtained from parents and pediatric patients. Individualized treatment plans were recommended by the IM team. Methods: Self-reported survey and electronic medical record data were collected about socioeconomic demographics, pain, use of medical and IM services, and quality of life. The authors compared health and quality of life indicators and costs of care for each participant from the year before entering the project with these same indicators for the subsequent year. Results: Eighty-three participants were enrolled. Participants ranged in age from 4 to 22 years (mean 14.7 years). Eighty percent of the group were females. Forty-two percent of the sample were white, 30% were Hispanic/Latinx, and 28% were African American. Primary types of pain were abdominal (52%), headache (23%), musculoskeletal (18%), and other (7%). Quality of life indicators improved (p = 0.049) and pain interference decreased (Wilcoxon p = 0.040). Major economic drivers of cost were emergency department (ED) visits, inpatient hospitalizations, and consultations with medical specialists. For the 46 participants who completed the project, the following total cost savings were noted: $27,819 (surgeries), $17,638 (ED visits), $25,033 (hospitalizations), and $42,843 (specialist consults). No adverse events were reported. Conclusion: The authors' experience demonstrated that the use of IM approaches in an interdisciplinary team approach is safe, feasible, and acceptable to families. Considerable cost savings were observed in the area of surgical procedures, hospitalizations, and consultations with specialists.

Patient engagement and presence in a virtual world world diabetes self-management education intervention for minority women.

OBJECTIVE: We aim to explore how users' experience of presence in a virtual world (VW) learning environment enhanced patient engagement in DSME/S programs conducted in an online VW platform with minority women with type 2 diabetes. METHODS: We conducted an embedded, mixed methods study, using a convergent study design to analyze qualitative field notes and interview data and quantitative survey data gathered from the Women in Control 2.0 (WIC2) clinical trial participants. The WIC2 clinical trial compared a diabetes group visit program delivered using an online VW platform versus an in-person approach. RESULT: We enrolled 158 VW participants, of which 144 completed baseline data, 124 completed the post-intervention follow up survey, and 30 participated in key informant and focus group interviews. Overall, participants reported a sense of social (63.7%, mean 3.7/5.0), physical (63.1%, mean 3.6/5.0), and self (49.0%, mean 3.3/5.0) presence while engaged in VW group DSME/S. Three themes emerged from mixed methods analysis including, 1) Participants' identification with their avatars enhances a sense of self presence in a VW, 2) physical presence enables visualization and imaginative play modalities of social learning, and 3) social presence cultivates meaningful social support and psychological safety. CONCLUSION: Our research empirically supports the premise that participants' experience of three domains of presence (self, physical and social) in a VW environment enhances participant engagement in DSME/S programs. PRACTICE IMPLICATIONS: Further research is warranted to study optimal approaches to implementation and dissemination of this novel approach to patient education and engagement.

Depression Predicts Chronic Pain Interference in Racially Diverse, Income-Disadvantaged Patients.

BACKGROUND: Chronic pain is one of the most common reason adults seek medical care in the United States, with prevalence estimates ranging from 11% to 40%. Mindfulness meditation has been associated with significant improvements in pain, depression, physical and mental health, sleep, and overall quality of life. Group medical visits are increasingly common and are effective at treating myriad illnesses, including chronic pain. Integrative Medical Group Visits (IMGV) combine mindfulness techniques, evidence based integrative medicine, and medical group visits and can be used as adjuncts to medications, particularly in diverse underserved populations with limited access to non-pharmacological therapies. OBJECTIVE AND DESIGN: The objective of the present study was to use a blended analytical approach of machine learning and regression analyses to evaluate the potential relationship between depression and chronic pain in data from a randomized clinical trial of IMGV in diverse, income-disadvantaged patients suffering from chronic pain and depression. METHODS: The analytical approach used machine learning to assess the predictive relationship between depression and pain and identify and select key mediators, which were then assessed with regression analyses. It was hypothesized that depression would predict the pain outcomes of average pain, pain severity, and pain interference. RESULTS: Our analyses identified and characterized a predictive relationship between depression and chronic pain interference. This prediction was mediated by high perceived stress, low pain self-efficacy, and poor sleep quality, potential targets for attenuating the adverse effects of depression on functional outcomes. CONCLUSIONS: In the context of the associated clinical trial and similar interventions, these insights may inform future treatment optimization, targeting, and application efforts in racialized, income-disadvantaged populations, demographics often neglected in studies of chronic pain.

Incorporating Acupuncture Into American Healthcare: Initiating a Discussion on Implementation Science, the Status of the Field, and Stakeholder Considerations.

INTRODUCTION: The field of implementation science is the study of methods that promote the uptake of evidence-based interventions into healthcare policy and practice. While acupuncture has gained significant traction in the American healthcare landscape, its journey has been somewhat haphazard and non-linear. METHODS: In June 2019, a group of thirty diverse stakeholders was convened by the Society for Acupuncture Research with the support of a Patient Centered Outcomes Research Institute, Eugene Washington Engagement Award. This group of stakeholders represented a diverse mix of patients, providers, academicians, researchers, funders, allied health professionals, insurers, association leaders, certification experts, and military program developers. The collective engaged in discussion that explored acupuncture's status in healthcare, including reflections on its safety, effectiveness, best practices, and the actual implementation of acupuncture as seen from diverse stakeholder viewpoints. OBJECTIVES: A primary goal was to consider how to utilize knowledge from the field of implementation science more systematically and intentionally to disseminate information about acupuncture and its research base, through application of methods known to implementation science. The group also considered novel challenges that acupuncture may present to known implementation processes. FINDINGS: This article summarizes the initial findings of this in-person meeting of stakeholders and the ongoing discussion among the subject matter experts who authored this report. The goal of this report is to catalyze greater conversation about how the field of implementation science might intersect with practice, access, research, and policymaking pertaining to acupuncture. Core concepts of implementation science and its relationship to acupuncture are introduced, and the case for acupuncture as an Evidence Based Practice (EBP) is established. The status of the field and current environment of acupuncture is examined, and the perspectives of four stakeholder groups--patients, two types of professional practitioners, and researchers--are explored in more detail.

A Teaching Kitchen Medical Groups Visit with an eHealth Platform for Hypertension and Cardiac Risk Factors: A Qualitative Feasibility Study.

Introduction: Our Whole Lives-Hypertension (OWL-H) is an eHealth toolkit for hypertension and cardiac risks factors. It is a hybrid online self-management platform that teaches blood pressure (BP) self-monitoring and evidence-based lifestyle modifications combined with in-person teaching kitchen medical group visit. Qualitative feedback from participants regarding the facilitators and barriers of using OWL-H has been discussed in this article. Methods: The OWL-H platform was pilot tested in a pre-post trial with two cohorts of participants with hypertension (N = 24). The online intervention utilized OWL-H for teaching mindfulness meditation, the Dietary Approaches to Stop Hypertension nutrition plan, and evidence-based strategies for lifestyle modifications. Three in-person teaching kitchen medical group visits were held to demonstrate cooking skills to reinforce the online platform. Semi-structured focus group discussions (FGDs) were held after the intervention. Results: Fourteen of the 24 participants in the trial participated in the FGDs, and 1 participant provided feedback in a solo interview. Major themes that emerged included: (1) participants' request to tailor OWL-H's recipes and meal planning to suit their own dietary needs or preferences, to personalize the Home Practices (e.g., meditation) according to individual preferences (e.g., addition of nature sounds or guided visual imagery); (2) the strengths and weaknesses of OWL-H as a BP self-monitoring tool; (3) the need for community support in managing BP; and (4) participants noted lack of time, work and commute, Internet connectivity, stress, and sickness as obstacles in using OWL-H. Participants described feeling outpaced by the growth of technology and raised concerns of poor Internet connectivity hampering their use of OWL-H. Conclusion: OWL-H and the accompanying teaching kitchen medical group visit are potential tools to help reduce hypertension and cardiac risk factors. The intervention was found to have acceptability among people with lower income. Clinical Trials Registration#: NCT03974334.

The design and methods of the OPTIMUM study: A multisite pragmatic randomized clinical trial of a telehealth group mindfulness program for persons with chronic low back pain.

Mindfulness-based stress reduction (MBSR) is an evidence-based non-pharmacological approach for chronic low back pain (cLBP), yet it is not readily available or reimbursable within primary care clinics. Primary care providers (PCPs) who wish to avoid prescribing opioids and other medications typically have few options for their cLBP patients. We present the protocol of a pragmatic clinical trial entitled OPTIMUM (Optimizing Pain Treatment In Medical settings Using Mindfulness). OPTIMUM is offered online via telehealth and includes medical group visits (MGV) with a PCP and a mindfulness meditation intervention modeled on MBSR for persons with cLBP. In diverse health-care settings in the US, such as a safety net hospital, federally qualified health centers, and a large academic health system, 450 patients will be assigned randomly to the MGV + MBSR or to usual PCP care alone. Participants will complete self-report surveys at baseline, following the 8-week program, and at 6- and 12-month follow-up. Health care utilization data will be obtained through electronic health records and via brief monthly surveys completed by participants. The primary outcome measure is the PEG (Pain, enjoyment, and general activity) at the 6-month follow-up. Additionally, we will assess psychological function, healthcare resource use, and opioid prescriptions. This trial, which is part of the NIH HEAL Initiative, has the potential to enhance primary care treatment of cLBP by combining PCP visits with a non-pharmacological treatment modeled on MBSR. Because it is offered online and integrated into primary care, it is expected to be scalable and accessible to underserved patients. Clinical Trials.gov: NCT04129450.

Stigma as a Barrier to Participant Recruitment of Minority Populations in Diabetes Research: Development of a Community-Centered Recruitment Approach.

BACKGROUND: The development of evidence-based care geared towards Black and Latina women living with uncontrolled type 2 diabetes is contingent upon their active recruitment into clinical interventions. Well-documented impediments to recruitment include a historical mistrust of the research community and socioeconomic factors that limit awareness and access to research studies. Although sociocultural and socioeconomic factors deter minorities from participating in clinical research, it is equally important to consider the role of stigma in chronic disease intervention studies. OBJECTIVE: We aim to share our discovery of diabetes-related stigma as an underrecognized impediment to recruitment for the Women in Control 2.0 virtual diabetes self-management education study. METHODS: Our initial recruitment plan used traditional strategies to recruit minority women with uncontrolled type 2 diabetes, which included letters and phone calls to targeted patients, referrals from clinicians, and posted flyers. After engaging a patient advisory group and consulting with experts in community advocacy, diabetes-related stigma emerged as a prominent barrier to recruitment. The study team reviewed and revised recruitment scripts and outreach material in order to better align with the lived experience and needs of potential enrollees. RESULTS: Using a more nuanced, community-centered recruitment approach, we achieved our target recruitment goal, enrolling 309 participants into the study, exceeding our target of 212. CONCLUSIONS: There is a need for updated recruitment methods that can increase research participation of patients who experience internalized diabetes stigma. To address disparities in minority health, further research is needed to better understand diabetes-related stigma and devise strategies to avert or address it.

Feasibility of Implementation Mapping for Integrative Medical Group Visits.

Objectives: Implementation science is key to translating complementary and integrative health intervention research into practice as it can increase accessibility and affordability while maximizing patient health outcomes. The authors describe using implementation mapping to (1) identify barriers and facilitators impacting the implementation of an Integrative Medical Group Visit (IMGV) intervention in an outpatient setting with a high burden of patients with chronic pain and (2) select and develop implementation strategies utilizing theory and stakeholder input to address those barriers and facilitators. Design: The authors selected a packaged, evidence-based, integrative pain management intervention, the IMGV, to implement in an outpatient clinic with a high burden of patients with chronic pain. The authors used implementation mapping to identify implementation strategies for IMGV, considering theory and stakeholder input. Stakeholder interviews with clinic staff, faculty, and administrators (n = 15) were guided by the Consolidated Framework for Implementation Research. Results: Based on interview data, the authors identified administrators, physicians, nursing staff, and scheduling staff as key stakeholders involved in implementation. Barriers and facilitators focused on knowledge, buy-in, and operational procedures needed to successfully implement IMGV. The implementation team identified three cognitive influences on behavior that would impact performance: knowledge, outcome expectations, and self-efficacy; and three theoretical change methods: cue to participate, communication, and mobilization. Implementation strategies identified included identifying and preparing champions, participation in ongoing training, developing and distributing educational materials, and organizing clinician implementation team meetings. Conclusions: This study provides an example of the application of implementation mapping to identify theory-driven implementation strategies for IMGV. Implementation mapping is a feasible method that may be useful in providing a guiding structure for implementation teams as they employ implementation frameworks and select implementation strategies for integrative health interventions.