Arne Beck

Practical clinical trials for translating research to practice: design and measurement recommendations.

Rationale:There is a pressing need for practical clinical trials (PCTs) that are more relevant to clinicians and decision-makers, but many are unaware of these trials. Furthermore, such trials can be challenging to conduct and to report. Objective:The objective of this study was to build on the seminal paper by Tunis et al (Practical clinical trials. Increasing the value of clinical research for decision making in clinical and health policy. JAMA. 2003;290:1624–1632.) and to provide recommendations and examples of how practical clinical trials can be conducted and the results reported to enhance external validity without sacrificing internal validity. Key Issues:We discuss evaluating practical intervention options, alternative research designs, representativeness of samples participating at both the patient and the setting/clinician level, and the need for multiple outcomes to address clinical and policy implications. Conclusions:We provide a set of specific recommendations for issues to be reported in PCTs to increase their relevance to clinicians and policymakers, and to help reduce the gap between research and practice.

A Randomized Trial of Group Outpatient Visits for Chronically Ill Older HMO Members: The Cooperative Health Care Clinic

OBJECTIVE: To compare the impact of group outpatient visits to traditional “physician‐patient dyad” care among older chronically ill HMO members on health services utilization and cost, self‐reported health status, and patient and physician satisfaction.

The association between work performance and physical activity, cardiorespiratory fitness, and obesity

Learning ObjectivesList the baseline characteristics of the nearly 700 individuals participating in this study of how modifiable lifestyle-related risk factors relate to job performance.Define whether, and in what ways, risk factor status was associated with work performance.Explain what these findings mean about choosing appropriate interventions to lessen absenteeism and improve job performance. The purpose of this study was to test the association between lifestyle-related modifiable health risks (physical activity, cardiorespiratory fitness, and obesity) and work performance. Data were obtained from 683 workers. Dependent variables included number of work loss days, quantity and quality of work performed, overall job performance, extra effort exerted, and interpersonal relationships. Results indicated that higher levels of physical activity related to reduced decrements in quality of work performed and overall job performance; higher cardiorespiratory fitness related to reduced decrements in quantity of work performed, and a reduction in extra effort exerted to perform the work; obesity related to more difficulty in getting along with coworkers; severe obesity related to a higher number of work loss days. It is concluded that lifestyle-related modifiable health risk factors significantly impact employee work performance.

Implementing Practical Interventions to Support Chronic Illness Self-Management

BACKGROUND Self-management support (SMS) is the area of disease management least often implemented and most challenging to integrate into usual care. This article outlines a model of SMS applicable across different chronic illnesses and health care systems, presents recommendations for assisting health care professionals and practice teams to make changes, and provides tips and lessons learned. Strategies can be applied across a wide range of conditions and settings by health educators, care managers, quality improvement specialists, researchers, program evaluators, and clinician leaders. Successful SMS programs involve changes at multiple levels: patient-clinician interactions; office environment changes; and health system, policy, and environmental supports. PATIENT-CLINICIAN INTERACTION LEVEL: Self-management by patients is not optional but inevitable because clinicians are present for only a fraction of the patients life, and nearly all outcomes are mediated through patient behavior. Clinicians who believe they are in control or responsible for a patients well-being are less able to adopt an approach that acknowledges the central role of the patient in his or her care. SUMMARY AND CONCLUSIONS Self-management should be an integral part of primary care, an ongoing iterative process, and patient centered; use collaborative goal setting and decision making; and include problem solving, outreach, and systematic follow-up.

Chronic medical conditions and work performance in the health and work performance questionnaire calibration surveys.

Associations between chronic conditions and work performance (absenteeism, presenteeism, and critical incidents) were studied in reservation agents, customer service representatives, executives, and railroad engineers. Conditions and work performance were assessed with the World Health Organization’s Health and Work Performance Questionnaire. Analysis of covariance was used to estimate associations. More work performance was lost from presenteeism than absenteeism. However, chronic conditions more consistently had negative impacts on absenteeism than presenteeism. Conditions with significant effects included arthritis, asthma, chronic obstructive pulmonary disease–emphysema, depression, and chronic headaches. Arthritis had the largest aggregate effect on absenteeism–presenteeism. Only depression affected both absenteeism–presenteeism and critical incidents. Some chronic conditions have substantial workplace effects. Disease management programs for these conditions might have a positive return on investment (ROI). Health and productivity tracking surveys are needed to evaluate ROI and provide quality assurance.

Multidisciplinary Team Care May Slow the Rate of Decline in Renal Function

BACKGROUND AND OBJECTIVES A multidisciplinary team (MDT) approach to chronic kidney disease (CKD) may help optimize care of CKD and comorbidities. We implemented an MDT quality improvement project for persons with stage 3 CKD and comorbid diabetes and/or hypertension. Our objective was to decrease the rate of decline of GFR. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We used a 4-year historical cohort to compare 1769 persons referred for usual nephrology care versus 233 referred for MDT care within an integrated, not-for-profit Health Maintenance Organization (HMO). Usual care consisted of referral to an outside nephrologist. The MDT consisted of an HMO-based nephrologist, pharmacy specialist, diabetes educator, dietitian, social worker, and nephrology nurse. Both groups received usual primary care. The primary outcome was rate of decline of GFR. Secondary outcomes were LDL, hemoglobin A1c, and BP. RESULTS In multivariate repeated-measures analyses, MDT care was associated with a mean annual decline in GFR of 1.2 versus 2.5 ml/min per 1.73 m(2) for usual care. In stratified analyses, the significant difference in GFR decline persisted only in those who completed their referrals. There were no differences in the secondary outcomes between groups. CONCLUSIONS In this integrated care setting, MDT care resulted in a slower decline in GFR than usual care. This occurred despite a lack of significant differences for secondary disease-specific measures, suggesting that other differences in the MDT population or care process accounted for the slower decline in GFR in the MDT group.

Severity of Depression and Magnitude of Productivity Loss

PURPOSE Depression is associated with lowered work functioning, including absences, impaired productivity, and decreased job retention. Few studies have examined depression symptoms across a continuum of severity in relationship to the magnitude of work impairment in a large and heterogeneous patient population, however. We assessed the relationship between depression symptom severity and productivity loss among patients initiating treatment for depression. METHODS Data were obtained from patients participating in the DIAMOND (Depression Improvement Across Minnesota: Offering a New Direction) initiative, a statewide quality improvement collaborative to provide enhanced depression care. Patients newly started on antidepressants were surveyed with the Patient Health Questionnaire 9-item screen (PHQ-9), a measure of depression symptom severity; the Work Productivity and Activity Impairment (WPAI) questionnaire, a measure of loss in productivity; and items on health status and demographics. RESULTS We analyzed data from the 771 patients who reported being currently employed. General linear models adjusting for demographics and health status showed a significant linear, monotonic relationship between depression symptom severity and productivity loss: with every 1-point increase in PHQ-9 score, patients experienced an additional mean productivity loss of 1.65% (P <.001). Even minor levels of depression symptoms were associated with decrements in work function. Full-time vs part-time employment status and self-reported fair or poor health vs excellent, very good, or good health were also associated with a loss of productivity (P <.001 and P=.045, respectively). CONCLUSIONS This study shows a relationship between the severity of depression symptoms and work function, and suggests that even minor levels of depression are associated with a loss of productivity. Employers may find it beneficial to invest in effective treatments for depressed employees across the continuum of depression severity.

Modeling the impact of enhanced depression treatment on workplace functioning and costs: a cost-benefit approach.

Background:The impact of depression on the workplace has been widely observed in studies examining absenteeism and reduced productivity during days at work. However, there is little scientific evidence about whether depression interventions are cost-beneficial to employers. Objective:We construct a cost–benefit analysis of depression treatment under different workplace assumptions better reflecting the nature of employment. Research Design:Data from a randomized controlled trial in which employed primary care patients with depression were treated in practices randomly assigned to an enhanced treatment intervention or usual care were used to construct a cost–benefit model from an employer perspective under different assumptions regarding employment. Subjects:A national sample of 198 workers employed in a range of positions by companies was studied. Measures:Benefits included self-reported productivity and absenteeism; costs included intervention and treatment costs. Net benefit was calculated under different scenarios and return on investment (ROI) is derived. Results:Enhanced depression treatment resulted in an average net benefit to the employer of

Factors that contribute to positive perceived health in an older population.

30 per participating worker in Year 1 of the intervention and

Sumatriptan treatment for migraine in a health maintenance organization: Economic, humanistic, and clinical outcomes

257 per participating worker in Year 2, for an estimated ROI during the 2-year period of 302%. ROI increased in firms that rely on team production, hire more costly substitute labor, or realize penalties for output shortfalls. ROI decreased in firms that have a large fraction of employees with dependent coverage and experience high turnover rates. Results also are sensitive to how subjectively reported productivity is valued. Conclusion:Many employers will receive a potentially significant ROI from depression treatment models that improve absenteeism and productivity at work.