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Duffy S.A.,University of Michigan | Scholten R.L.,University of Michigan | Karvonen-Gutierrez C.A.,Ann Arbor Center for Clinical Management Research
Preventive Medicine

Objective: The objective of this study was to determine if tobacco use while in the hospital was associated with post-discharge cessation rates. Methods: During 2006-2008, smokers from three Veterans Affairs hospitals (n= 354) were surveyed during their hospitalization and again 6 months later. Data analysis was conducted in 2009. Results: While veterans smoked an average of 19 cigarettes per day, prior to admission, the average was 6-7 cigarettes per day during hospitalization. About 40% (n= 140) were able to quit smoking for more than 24 h and the median days quit was 29. The 6-month self-reported quit rate was 15% (n= 53). Multivariate analyses showed that veterans who quit tobacco use during their hospitalization had nearly 4 times increased odds of quitting smoking for more than 24 h and 2.7 times increased odds of quitting at 6 months post-hospitalization as compared to veterans that did not quit using tobacco during hospitalization. Conclusion: Many veterans quit tobacco use during hospital admissions and those who do not quit, tended to decrease their use. Veterans who quit tobacco use were more likely to be abstinent at 6-month follow-up. State-of-the-art cessation interventions need to be provided to smokers hospitalized in Veterans Affairs hospitals. © 2010. Source

Noonan D.,University of Michigan | Jiang Y.,University of Michigan | Duffy S.A.,University of Michigan | Duffy S.A.,Ann Arbor Center for Clinical Management Research
Addictive Behaviors

Research on the validity of self-report tobacco use has varied by the population studied and has yet to be examined among smokers serviced by the Department of Veterans Affairs (VA). The purpose of this study was to determine the predictors of returning a biochemical urine test and the specificity and sensitivity of self-reported tobacco use status compared to biochemical verification. This was a sub-analysis of the larger Tobacco Tactics research study, a pre-/post-non-randomized control design study to implement and evaluate a smoking cessation intervention in three large VA hospitals. Inpatient smokers completed baseline demographic, health history and tobacco use measures. Patients were sent a follow-up survey at six-months to assess tobacco use and urine cotinine levels. A total of 645 patients returned six-month surveys of which 578 also returned a urinary cotinine strip at six-months. Multivariate analysis of the predictors of return rate revealed those more likely to return biochemical verification of their smoking status were younger, more likely to be thinking about quitting smoking, have arthritis, and less likely to have heart disease. The sensitivity and specificity of self-report tobacco use were 97% (95% confidence interval = 0.95-0.98) and 93% (95% confidence interval = 0.84-0.98) respectively. The misclassification rate among self-reported quitters was 21%. The misclassification rate among self-reported tobacco users was 1%. The sensitivity and specificity of self-report tobacco use were high among veteran smokers, yet among self-report quitters that misclassification rate was high at 21% suggesting that validating self-report tobacco measures is warranted in future studies especially in populations that are prone to misclassification. © 2012. Source

Tang T.S.,University of British Columbia | Funnell M.,University of Michigan | Sinco B.,University of Michigan | Piatt G.,University of Michigan | And 5 more authors.
Diabetes Care

OBJECTIVE To compare a peer leader (PL) versus a community health worker (CHW) telephone outreach intervention in sustaining improvements in HbA1c over 12 months after a 6-month diabetes self-management education (DSME) program. RESEARCH DESIGN AND METHODS One hundred and sixteen Latino adults with type 2 diabetes were recruited froma federally qualified health center and randomized to 1) a 6-month DSME program followed by 12 months of weekly group sessions delivered by PLs with telephone outreach to those unable to attend or 2) a 6-month DSME programfollowed by 12 months ofmonthly telephone outreach delivered by CHWs. The primary outcome was HbA1c. Secondary outcomes were cardiovascular disease risk factors, diabetes distress, and diabetes social support. Assessments were conducted at baseline, 6, 12, and 18 months. RESULTS After DSME, the PL group achieved a reduction in mean HbA1c (8.2-7.5% or 66-58 mmol/mol, P < 0.0001) that wasmaintained at 18months (20.6%or26.6mmol/mol from baseline [P = 0.009]). TheCHW group also showed a reduction in HbA1c (7.8 vs. 7.3% or 62 vs. 56 mmol/mol, P = 0.0004) post-6 month DSME; however, it was attenuated at 18 months (20.3% or 23.3 mmol/mol from baseline, within-group P = 0.234). Only the PL group maintained improvements achieved in blood pressure at 18 months. At the 18-month follow-up, both groups maintained improvements in waist circumference, diabetes support, and diabetes distress, with no significant differences between groups. CONCLUSIONS Both low-cost maintenance programs led by either a PL or a CHW maintained improvements in key patient-reported diabetes outcomes, but the PL intervention may have additional benefit in sustaining clinical improvements beyond 12 months. © 2014 by the American Diabetes Association. Source

O'Donnell A.N.,Ann Arbor Center for Clinical Management Research | Williams M.,Health Integrated | Kilbourne A.M.,Ann Arbor Center for Clinical Management Research | Kilbourne A.M.,University of Michigan
Journal of General Internal Medicine

The Chronic Care Model (CCM) has been shown to improve medical and psychiatric outcomes for persons with mental disorders in primary care settings, and has been proposed as a model to integrate mental health care in the patient-centered medical home under healthcare reform. However, the CCM has not been widely implemented in primary care settings, primarily because of a lack of a comprehensive reimbursement strategy to compensate providers for day-to-day provision of its core components, including care management and provider decision support. Drawing upon the existing literature and regulatory guidelines, we provide a critical analysis of challenges and opportunities in reimbursing CCM components under the current fee-for-service system, and describe an emerging financial model involving bundled payments to support core CCM components to integrate mental health treatment into primary care settings. Ultimately, for the CCM to be used and sustained over time to integrate physical and mental health care, effective reimbursement models will need to be negotiated across payers and providers. Such payments should provide sufficient support for primary care providers to implement practice redesigns around core CCM components, including care management, measurement-based care, and mental health specialist consultation. © 2013 Society of General Internal Medicine. Source

Goldberger Z.D.,University of Washington | Nallamothu B.K.,University of Michigan | Nallamothu B.K.,Ann Arbor Center for Clinical Management Research | Nichol G.,University of Washington | And 3 more authors.
Circulation: Cardiovascular Quality and Outcomes

Background - A growing number of hospitals have begun to implement policies allowing for family presence during resuscitation (FPDR). However, the overall safety of these policies and their effect on resuscitation care is unknown. Methods and Results - We conducted an observational cohort study of 252 hospitals in the United States with 41 568 adults with cardiac arrest. Multivariable hierarchical regression models were used to evaluate patterns of care at hospitals with and without an FPDR policy. Primary outcomes included return of spontaneous circulation and survival to discharge. Secondary outcomes included resuscitation quality, interventions, and facility-reported potential resuscitation systems errors. There were no significant differences in facility characteristics between hospitals with and without an FPDR policy, nor were there significant differences in return of spontaneous circulation (adjusted risk ratio, 1.02; 95% confidence interval, 0.95-1.06) or survival to discharge (adjusted risk ratio, 1.05; 95% confidence interval, 0.95-1.15). There was a small, borderline significant decrease in the mean time to defibrillation at hospitals with an FPDR policy compared with hospitals without the policy (mean difference, 0.32 minutes; 95% confidence interval, -0.01 to 0.64). Resuscitation quality, interventions, and facility-reported potential resuscitation systems errors did not meaningfully differ between hospitals with and without an FPDR policy. Conclusions - Hospitals with an FPDR policy generally have no statistically significant differences in outcomes and processes of care as hospitals without this policy, suggesting such policies may not negatively affect resuscitation care. Further study is warranted about the direct effect of FPDR attempts on adult patients with an in-hospital cardiac arrest and their families. © 2015 American Heart Association, Inc. Source

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