David E. Goodrich

Randomized controlled trial to assess reduction of cardiovascular disease risk in patients with bipolar disorder: the Self-Management Addressing Heart Risk Trial (SMAHRT).

OBJECTIVES Persons with bipolar disorder experience a disproportionate burden of medical conditions, notably cardiovascular disease (CVD), leading to impaired functioning and premature mortality. We hypothesized that the Life Goals Collaborative Care (LGCC) intervention, compared to enhanced usual care, would reduce CVD risk factors and improve physical and mental health outcomes in US Department of Veterans Affairs patients with bipolar disorder. METHOD Patients with an ICD-9 diagnosis of bipolar disorder and ≥ 1 CVD risk factor (N = 118) enrolled in the Self-Management Addressing Heart Risk Trial, conducted April 2008-May 2010, were randomized to LGCC (n = 58) or enhanced usual care (n = 60). Life Goals Collaborative Care included 4 weekly self-management sessions followed by tailored contacts combining health behavior change strategies, medical care management, registry tracking, and provider guideline support. Enhanced usual care included quarterly wellness newsletters sent during a 12-month period in addition to standard treatment. Primary outcome measures included systolic and diastolic blood pressure, nonfasting total cholesterol, and physical health-related quality of life. RESULTS Of the 180 eligible patients identified for study participation, 134 were enrolled (74%) and 118 completed outcomes assessments (mean age = 53 years, 17% female, 5% African American). Mixed effects analyses comparing changes in 24-month outcomes among patients in LGCC (n = 57) versus enhanced usual care (n = 59) groups revealed that patients receiving LGCC had reduced systolic (β = -3.1, P = .04) and diastolic blood pressure (β = -2.1, P = .04) as well as reduced manic symptoms (β = -23.9, P = .01). Life Goals Collaborative Care had no significant impact on other primary outcomes (total cholesterol and physical health-related quality of life). CONCLUSIONS Life Goals Collaborative Care, compared to enhanced usual care, may lead to reduced CVD risk factors, notably through decreased blood pressure, as well as reduced manic symptoms, in patients with bipolar disorder. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT00499096.

A small-change approach delivered via telephone promotes weight loss in veterans: Results from the ASPIRE-VA pilot study

OBJECTIVE High rates of overweight and obesity (70%) among US veterans pose a significant threat of obesity-related chronic disease and disability. The purpose of this pilot study was to demonstrate feasibility and impact of a phone-based small-change weight loss intervention (ASPIRE-VA) with veterans. METHODS Participants received a pedometer, food log book, and treatment manual outlining the small change program. Participants then scheduled weekly phone calls with a lifestyle coach, during which they reviewed the prior weeks goals and developed new goals for the following week. Primary outcome was weight loss measured at 12 weeks, compared to baseline. RESULTS Fourteen sedentary (4471+/-2315 steps per day), obese (37.0+/-4.2 BMI), middle aged (53.8+/-12.5) male (64%) and female (36%) participants were enrolled. At 12 weeks participants exhibited significant weight loss (-3.8+/-3.6 kg; p=.002) and increased intake of fruits and vegetables (+2.2+/-3.1 daily servings; p=.03); though no change in walking (+786+/-2288 daily steps; p=.24). CONCLUSION Results suggest that a phone-based small change program is feasible and beneficial for promoting weight loss in overweight/obese veterans. PRACTICE IMPLICATIONS This telephone-based program has the potential to reduce rates of overweight and obesity among veterans and thus prevent and improve prognosis of associated chronic conditions.

Evaluating Active U: an internet-mediated physical activity program

BackgroundEngaging in regular physical activity can be challenging, particularly during the winter months. To promote physical activity at the University of Michigan during the winter months, an eight-week Internet-mediated program (Active U) was developed providing participants with an online physical activity log, goal setting, motivational emails, and optional team participation and competition.MethodsThis study is a program evaluation of Active U. Approximately 47,000 faculty, staff, and graduate students were invited to participate in the online Active U intervention in the winter of 2007. Participants were assigned a physical activity goal and were asked to record each physical activity episode into the activity log for eight weeks. Statistics for program reach, effectiveness, adoption, and implementation were calculated using the Re-Aim framework. Multilevel regression analyses were used to assess the decline in rates of data entry and goal attainment during the program, to assess the likelihood of joining a team by demographic characteristics, to test the association between various predictors and the number of weeks an individual met his or her goal, and to analyze server load.ResultsOverall, 7,483 individuals registered with the Active U website (≈16% of eligible), and 79% participated in the program by logging valid data at least once. Staff members, older participants, and those with a BMI < 25 were more likely to meet their weekly physical activity goals, and average rate of meeting goals was higher among participants who joined a competitive team compared to those who participated individually (IRR = 1.28, P < .001).ConclusionInternet-mediated physical activity interventions that focus on physical activity logging and goal setting while incorporating team competition may help a significant percentage of the target population maintain their physical activity during the winter months.

An Internet-Mediated Pedometer-Based Program Improves Health-Related Quality-of-Life Domains and Daily Step Counts in COPD

BACKGROUND Low levels of physical activity (PA) are associated with poor outcomes in people with COPD. Interventions to increase PA could improve outcomes. METHODS We tested the efficacy of a novel Internet-mediated, pedometer-based exercise intervention. Veterans with COPD (N = 239) were randomized in a 2:1 ratio to the (1) intervention group (Omron HJ-720 ITC pedometer and Internet-mediated program) or (2) wait-list control group (pedometer). The primary outcome was health-related quality of life (HRQL), assessed by the St. Georges Respiratory Questionnaire (SGRQ), at 4 months. We examined the SGRQ total score (SGRQ-TS) and three domain scores: Symptoms, Activities, and Impact. The secondary outcome was daily step counts. Linear regression models assessed the effect of intervention on outcomes. RESULTS Participants had a mean age of 67 ± 9 years, and 94% were men. There was no significant between-group difference in mean 4-month SGRQ-TS (2.3 units, P = .14). Nevertheless, a significantly greater proportion of intervention participants than control subjects had at least a 4-unit improvement in SGRQ-TS, the minimum clinically important difference (53% vs 39%, respectively, P = .05). For domain scores, the intervention group had a lower (reflecting better HRQL) mean than the control group by 4.6 units for Symptoms (P = .046) and by 3.3 units for Impact (P = .049). There was no significant difference in Activities score between the two groups. Compared with the control subjects, intervention participants walked 779 more steps per day at 4 months (P = .005). CONCLUSIONS An Internet-mediated, pedometer-based walking program can improve domains of HRQL and daily step counts at 4 months in people with COPD. TRIAL REGISTRY Clinical Trials.gov; No.: NCT01102777; URL: www.clinicaltrials.gov.

A systematic exploration of differences in contextual factors related to implementing the MOVE! weight management program in VA: a mixed methods study.

BackgroundIn January 2006, Veterans Affairs (VA) disseminated the MOVE!® Weight Management Program to VA medical centers to address the high prevalence of overweight/obesity. In its second year, MOVE! implementation varied widely across facilities. The objective of this study was to understand contextual factors that facilitated or impeded implementation of MOVE! in VA medical centers in the second year after its dissemination.MethodsWe used an embedded mixed methods cross-sectional study design. Qualitative and quantitative data were collected simultaneously with the primary purpose to explore contextual factors most likely to influence MOVE! implementation effectiveness at five purposively selected facilities. Facilities were selected to maximize variation with respect to participation in MOVE! by candidate Veterans. Semi-structured phone interviews were conducted with 24 staff across the five facilities. Quantitative responses were elicited followed by open-ended questions. The quantitative measures were adapted from a published implementation model. Qualitative analysis was conducted using rigorous content analysis methods.ResultsQualitative and quantitative data converged to strengthen findings that point to several recommendations. Management support can help increase visibility of the program, commit needed resources, and communicate the importance of implementation efforts. Establishing a receptive implementation climate can be accomplished by emphasizing the important role that weight management may have in reducing incidence and severity of obesity-related chronic conditions. Coalescing highly functioning multi-disciplinary teams was an essential step for more effective implementation of MOVE!. In some situations, local champions can overcome challenging barriers in facilities that lack sufficient management support.ConclusionsKey organizational factors at local VA medical centers were strongly associated with MOVE! implementation. Results pointed to recommendations that can help accelerate large-scale dissemination of complex weight management programs.

Mental Health Collaborative Care and Its Role in Primary Care Settings

Collaborative care models (CCMs) provide a pragmatic strategy to deliver integrated mental health and medical care for persons with mental health conditions served in primary care settings. CCMs are team-based intervention to enact system-level redesign by improving patient care through organizational leadership support, provider decision support, and clinical information systems, as well as engaging patients in their care through self-management support and linkages to community resources. The model is also a cost-efficient strategy for primary care practices to improve outcomes for a range of mental health conditions across populations and settings. CCMs can help achieve integrated care aims underhealth care reform yet organizational and financial issues may affect adoption into routine primary care. Notably, successful implementation of CCMs in routine care will require alignment of financial incentives to support systems redesign investments, reimbursements for mental health providers, and adaptation across different practice settings and infrastructure to offer all CCM components.

Life Goals Collaborative Care for patients with bipolar disorder and cardiovascular disease risk.

OBJECTIVE This pilot study compared Life Goals Collaborative Care (LGCC) with enhanced treatment as usual in reducing cardiometabolic risk factors and improving outcomes for persons with bipolar disorder. METHODS Participants were randomly assigned to LGCC (N=34) or enhanced treatment as usual (N=34). LGCC included four weekly self-management sessions and monthly telephone contacts for six months thereafter. Enhanced treatment as usual included wellness mailings. Outcomes were blood pressure, body mass index (BMI), quality of life, functioning, and symptoms. RESULTS Compared with enhanced treatment as usual, LGCC was not associated with reductions in cardiometabolic risk factors in 12-month repeated-measures analyses. Among patients with a BMI of ≥30 or systolic blood pressure of ≥140, LGCC was associated with improvements in functioning (beta=-2.2 and beta=-3.8, respectively, p=.04) and reduced depressive symptoms (beta=-2.0 and -3.5, respectively, p=.04). CONCLUSIONS Further research is needed to determine whether LGCC improves outcomes for patients with elevated cardiometabolic risk.

Eight-Year Trends of Cardiometabolic Morbidity and Mortality in Patients with Schizophrenia

OBJECTIVE We examined cardiometabolic disease and mortality over 8 years among individuals with and without schizophrenia. METHOD We compared 65,362 patients in the Veteran Affairs (VA) health system with schizophrenia to 65,362 VA patients without serious mental illness (non-SMI) matched on age, service access year and location. The annual prevalence of diagnosed cardiovascular disease, diabetes, dyslipidemia, hypertension, obesity, and all-cause and cause-specific mortality was compared for fiscal years 2000-2007. Mean years of potential life lost (YPLLs) were calculated annually. RESULTS The cohort was mostly male (88%) with a mean age of 54 years. Cardiometabolic disease prevalence increased in both groups, with non-SMI patients having higher disease prevalence in most years. Annual between-group differences ranged from <1% to 6%. Annual mortality was stable over time for schizophrenia (3.1%) and non-SMI patients (2.6%). Annual mean YPLLs increased from 12.8 to 15.4 in schizophrenia and from 11.8 to 14.0 for non-SMI groups. CONCLUSIONS VA patients with and without schizophrenia show increasing but similar prevalence rates of cardiometabolic diseases. YPLLs were high in both groups and only slightly higher among patients with schizophrenia. The findings highlight the complex population served by the VA while suggesting a smaller mortality impact from schizophrenia than previously reported.

National evaluation of obesity screening and treatment among veterans with and without mental health disorders

OBJECTIVE The objective was to determine whether obesity screening and weight management program participation and outcomes are equitable for individuals with serious mental illness (SMI) and depressive disorder (DD) compared to those without SMI/DD in Veterans Health Administration (VHA), the largest integrated US health system, which requires obesity screening and offers weight management to all in need. METHODS We used chart-reviewed, clinical and administrative VHA data from fiscal years 2010-2012 to estimate obesity screening and participation in the VHAs weight management program (MOVE!) across groups. Six- and 12-month weight changes in MOVE! participants were estimated using linear mixed models adjusted for confounders. RESULTS Compared to individuals without SMI/DD, individuals with SMI or DD were less frequently screened for obesity (94%-94.7% vs. 95.7%) but had greater participation in MOVE! (10.1%-10.4% vs. 7.4%). MOVE! participants with SMI or DD lost approximately 1 lb less at 6 months. At 12 months, average weight loss for individuals with SMI or neither SMI/DD was comparable (-3.5 and -3.3 lb, respectively), but individuals with DD lost less weight (mean=-2.7 lb). CONCLUSIONS Disparities in obesity screening and treatment outcomes across mental health diagnosis groups were modest. However, participation in MOVE! was low for every group, which limits population impact.

High‐frequency binge eating predicts weight gain among veterans receiving behavioral weight loss treatments

To assess for the frequency of binge eating behavior and its association with weight loss in an overweight/obese sample of veterans.