Laura M. Bonner

Informatics Systems to Promote Improved Care for Chronic Illness: A Literature Review

OBJECTIVE To understand information systems components important in supporting team-based care of chronic illness through a literature search. DESIGN Systematic search of literature from 1996-2005 for evaluations of information systems used in the care of chronic illness. MEASUREMENTS The relationship of design, quality, information systems components, setting, and other factors with process, quality outcomes, and health care costs was evaluated. RESULTS In all, 109 articles were reviewed involving 112 information system descriptions. Chronic diseases targeted included diabetes (42.9% of reviewed articles), heart disease (36.6%), and mental illness (23.2%), among others. System users were primarily physicians, nurses, and patients. Sixty-seven percent of reviewed experiments had positive outcomes; 94% of uncontrolled, observational studies claimed positive results. Components closely correlated with positive experimental results were connection to an electronic medical record, computerized prompts, population management (including reports and feedback), specialized decision support, electronic scheduling, and personal health records. Barriers identified included costs, data privacy and security concerns, and failure to consider workflow. CONCLUSION The majority of published studies revealed a positive impact of specific health information technology components on chronic illness care. Implications for future research and system designs are discussed.

Diet Intervention and Cerebrospinal Fluid Biomarkers in Amnestic Mild Cognitive Impairment

OBJECTIVE To compare the effects of a 4-week high-saturated fat/high-glycemic index (HIGH) diet with a low-saturated fat/low-glycemic index (LOW) diet on insulin and lipid metabolism, cerebrospinal fluid (CSF) markers of Alzheimer disease, and cognition for healthy adults and adults with amnestic mild cognitive impairment (aMCI). DESIGN Randomized controlled trial. SETTING Veterans Affairs Medical Center clinical research unit. PARTICIPANTS Forty-nine older adults (20 healthy adults with a mean [SD] age of 69.3 [7.4] years and 29 adults with aMCI with a mean [SD] age of 67.6 [6.8] years). INTERVENTION Participants received the HIGH diet (fat, 45% [saturated fat, > 25%]; carbohydrates, 35%-40% [glycemic index, > 70]; and protein, 15%-20%) or the LOW diet (fat, 25%; [saturated fat, < 7%]; carbohydrates, 55%-60% [glycemic index, < 55]; and protein, 15%-20%) for 4 weeks. Cognitive tests, an oral glucose tolerance test, and lumbar puncture were conducted at baseline and during the fourth week of the diet. MAIN OUTCOME MEASURES The CSF concentrations of β-amyloid (Aβ42 and Aβ40), tau protein, insulin, F2-isoprostanes, and apolipoprotein E, plasma lipids and insulin, and measures of cognition. RESULTS For the aMCI group, the LOW diet increased CSF Aβ42 concentrations, contrary to the pathologic pattern of lowered CSF Aβ42 typically observed in Alzheimer disease. The LOW diet had the opposite effect for healthy adults, ie, decreasing CSF Aβ42, whereas the HIGH diet increased CSF Aβ42. The CSF apolipoprotein E concentration was increased by the LOW diet and decreased by the HIGH diet for both groups. For the aMCI group, the CSF insulin concentration increased with the LOW diet, but the HIGH diet lowered the CSF insulin concentration for healthy adults. The HIGH diet increased and the LOW diet decreased plasma lipids, insulin, and CSF F2-isoprostane concentrations. Delayed visual memory improved for both groups after completion of 4 weeks of the LOW diet. CONCLUSION Our results suggest that diet may be a powerful environmental factor that modulates Alzheimer disease risk through its effects on central nervous system concentrations of Aβ42, lipoproteins, oxidative stress, and insulin.

Information Technology to Support Improved Care For Chronic Illness

BackgroundIn populations with chronic illness, outcomes improve with the use of care models that integrate clinical information, evidence-based treatments, and proactive management of care. Health information technology is believed to be critical for efficient implementation of these chronic care models. Health care organizations have implemented information technologies, such as electronic medical records, to varying degrees. However, considerable uncertainty remains regarding the relative impact of specific informatics technologies on chronic illness care.ObjectiveTo summarize knowledge and increase expert consensus regarding informatics components that support improvement in chronic illness care. Design: A systematic review of the literature was performed. “Use case” models were then developed, based on the literature review, and guidance from clinicians and national quality improvement projects. A national expert panel process was conducted to increase consensus regarding information system components that can be used to improve chronic illness care.ResultsThe expert panel agreed that informatics should be patient-centered, focused on improving outcomes, and provide support for illness self-management. They concurred that outcomes should be routinely assessed, provided to clinicians during the clinical encounter, and used for population-based care management. It was recommended that interactive, sequential, disorder-specific treatment pathways be implemented to quickly provide clinicians with patient clinical status, treatment history, and decision support.ConclusionsSpecific informatics strategies have the potential to improve care for chronic illness. Software to implement these strategies should be developed, and rigorously evaluated within the context of organizational efforts to improve care.

Effect of apolipoprotein e genotype and diet on apolipoprotein e lipidation and amyloid peptides randomized clinical trial

IMPORTANCE Sporadic Alzheimer disease (AD) is caused in part by decreased clearance of the β-amyloid (Aβ) peptide breakdown products. Lipid-depleted (LD) apolipoproteins are less effective at binding and clearing Aβ, and LD Aβ peptides are more toxic to neurons. However, not much is known about the lipid states of these proteins in human cerebrospinal fluid. OBJECTIVE To characterize the lipidation states of Aβ peptides and apolipoprotein E in the cerebrospinal fluid in adults with respect to cognitive diagnosis and APOE ε4 allele carrier status and after a dietary intervention. DESIGN Randomized clinical trial. SETTING Veterans Affairs Medical Center clinical research unit. PARTICIPANTS Twenty older adults with normal cognition (mean [SD] age, 69 [7] years) and 27 with amnestic mild cognitive impairment (67 [6] years). INTERVENTIONS Randomization to a diet high in saturated fat content and with a high glycemic index (High diet; 45% of energy from fat [>25% saturated fat], 35%-40% from carbohydrates with a mean glycemic index >70, and 15%-20% from protein) or a diet low in saturated fat content and with a low glycemic index (Low diet; 25% of energy from fat [<7% saturated fat], 55%-60% from carbohydrates with a mean glycemic index <55, and 15%-20% from protein). MAIN OUTCOMES AND MEASURES Lipid-depleted Aβ42 and Aβ40 and apolipoprotein E in cerebrospinal fluid. RESULTS Baseline levels of LD Aβ were greater for adults with mild cognitive impairment compared with adults with normal cognition (LD Aβ42, P = .05; LD Aβ40, P = .01). These findings were magnified in adults with mild cognitive impairment and the ε4 allele, who had higher LD apolipoprotein E levels irrespective of cognitive diagnosis (P < .001). The Low diet tended to decrease LD Aβ levels, whereas the High diet increased these fractions (LD Aβ42, P = .01; LD Aβ40, P = .15). Changes in LD Aβ levels with the Low diet negatively correlated with changes in cerebrospinal fluid levels of insulin (LD Aβ42 and insulin, r = -0.68 [P = .01]; LD Aβ40 and insulin, r = -0.78 [P = .002]). CONCLUSIONS AND RELEVANCE The lipidation states of apolipoproteins and Aβ peptides in the brain differ depending on APOE genotype and cognitive diagnosis. Concentrations can be modulated by diet. These findings may provide insight into the mechanisms through which apolipoprotein E4 and unhealthy diets impart risk for developing AD.

A randomized, placebo-controlled trial of intranasal insulin in amnestic MCI and early Alzheimer's

Background: Although not acknowledged by DSM-IV for example, attentional dysfunction is now recognised as a core cognitive symptom in Alzheimer’s disease (AD). The deficits are pronounced, directly related to disease severity, progress at a comparable rate to other deficits and respond well to treatment. In other dementias, such as Dementia with Lewy Bodies (DLB) and Parkinson’s Disease Dementia (PDD), recent consensus criteria recognize deficits to attention as central features of the conditions which should be evaluated in therapeutic trials. Methods: Much of the evidence for these deficits has been generated by the CDR System, an integrated set of automated tests of attention and memory. This paper will present the largest database of attentional deficits ever assembled from computerised testing in various dementia populations. Results: Data from over 3000 patients identifies differing profiles of attention deficits in AD, DLB, PDD, vascular dementia, Huntington’s disease and delirium. The rates of declines vary between the different groups as do the behavioural implications. The deficits to attention in AD, DLB and PDD respond to various treatments including donepezil, rivastigmine and galantamine. Conclusions: It will be concluded that attention is a major component of the cognitive dysfunction in all types of dementia, and that tests of attention should be part of the assessment profile in all therapeutic trials in the various conditions.

Stigma Predicts Treatment Preferences and Care Engagement Among Veterans Affairs Primary Care Patients with Depression

BackgroundWhereas stigma regarding mental health concerns exists, the evidence for stigma as a depression treatment barrier among patients in Veterans Affairs (VA) primary care (PC) is mixed.PurposeThis study tests whether stigma, defined as depression label avoidance, predicted patients’ preferences for depression treatment providers, patients’ prospective engagement in depression care, and care quality.MethodsWe conducted cross-sectional and prospective analyses of existing data from 761 VA PC patients with probable major depression.ResultsRelative to low-stigma patients, those with high stigma were less likely to prefer treatment from mental health specialists. In prospective controlled analyses, high stigma predicted lower likelihood of the following: taking medications for mood, treatment by mental health specialists, treatment for emotional concerns in PC, and appropriate depression care.ConclusionsHigh stigma is associated with lower preferences for care from mental health specialists and confers risk for minimal depression treatment engagement.

A preliminary exploration of the feasibility of offering men information about potential prostate cancer treatment options before they know their biopsy results

BackgroundA small pre-test study was conducted to ascertain potential harm and anxiety associated with distributing information about possible cancer treatment options at the time of biopsy, prior to knowledge about a definitive cancer diagnosis. Priming men about the availability of multiple options before they have a confirmed diagnosis may be an opportunity to engage patients in more informed decision-making.MethodsMen with an elevated PSA test or suspicious Digital Rectal Examination (DRE) who were referred to a urology clinic for a biopsy were randomized to receive either the clinic’s usual care (UC) biopsy instruction sheet (n = 11) or a pre-biopsy educational (ED) packet containing the biopsy instruction sheet along with a booklet about the biopsy procedure and a prostate cancer treatment decision aid originally written for newly diagnosed men that described in detail possible treatment options (n = 18).ResultsA total of 62% of men who were approached agreed to be randomized, and 83% of the ED group confirmed they used the materials. Anxiety scores were similar for both groups while awaiting the biopsy procedure, with anxiety scores trending lower in the ED group: 41.2 on a prostate-specific anxiety instrument compared to 51.7 in the UC group (p = 0.13). ED participants reported better overall quality of life while awaiting biopsy compared to the UC group (76.4 vs. 48.5, p = 0.01). The small number of men in the ED group who went on to be diagnosed with cancer reported being better informed about the risks and side effects of each option compared to men diagnosed with cancer in the UC group (p = 0.07). In qualitative discussions, men generally reported they found the pre-biopsy materials to be helpful and indicated having information about possible treatment options reduced their anxiety. However, 2 of 18 men reported they did not want to think about treatment options until after they knew their biopsy results.ConclusionsIn this small sample offering pre-biopsy education about potential treatment options was generally well received by patients, appeared to be beneficial to men who went on to be diagnosed, and did not appear to increase anxiety unnecessarily among those who had a negative biopsy.

Relationships between mood and employment over time among depressed VA primary care patients

OBJECTIVE Associations between depression, productivity and work loss have been reported, yet few studies have examined relationships between longitudinal depression status and employment continuity. We assessed these relationships among Veterans of conventional working ages. METHODS We used longitudinal survey data from Veterans receiving primary care in 1 of 10 Veterans Health Administration primary care practices in five states. Our sample included 516 participants with nine-item Patient Health Questionnaire (PHQ-9) scores indicating probable major depression (PHQ-9≥10) at baseline and who completed either the 7-month follow-up survey or follow-up surveys at both 7 and 18 months postbaseline. We examined relationships between depression persistence and employment status using multinomial logistic regression models. RESULTS Although general employment rates remained stable (21%-23%), improved depression status was associated with an increased likelihood of becoming employed over 7 months among those who were both depressed and nonemployed at baseline. Improvements in depression status starting at 7 months and continuing through 18 months were associated with remaining employed over the 18-month period, relative to those who were depressed throughout the same time frame. CONCLUSIONS Given the pressing need to prevent socioeconomic deterioration in the increasing population of conventional working-aged Operation Enduring Freedom and Operation Iraqi Freedom Veterans, further attention to the depression/employment relationship is urgently needed.

Evaluation of an implementation facilitation strategy for settings that experience significant implementation barriers.

Panel overview Though several implementation and quality improvement strategies have been shown to be effective in implementing programs and practices in routine clinical settings [1,2], little work has been done in developing and testing implementation strategies in settings that experience significant implementation barriers. This VA funded study evaluated a highly partnered implementation facilitation (IF) strategy [3] within the context of a Department of Veteran Affairs (VA) mandate for implementation of Primary Care-Mental Health Integration (PC-MHI) [4]. The IF strategy consisted of a national expert external facilitator (EF) and two internal regional facilitators (IRFs) who partnered with regional, medical center, and clinic leadership and staff in two VA regional networks to implement PC-MHI. Facilitators helped partners design/adapt their PC-MHI programs, develop site-specific implementation plans, and identify/address implementation barriers. They also identified and engaged key stakeholders at all organizational levels; conducted academic detailing, marketing, staff training, patient education, formative evaluation, and audit and feedback; assisted with technical issues; and established learning collaboratives. The EF had expertise in the evidence-base for PC-MHI and implementation activities. The IRF had protected time to support implementation activities, was embedded within the clinical organization at the regional level, and was familiar with local and regional organizational structures, procedures, culture, and clinical processes. We used a quasi-experimental, Hybrid Type III design [5] and mixed methods to test effectiveness of the IF strategy and document IF activities. National VA MH leadership has adopted this IF strategy for sites facing challenges to adopting evidencebased practices [4,6,7]. This panel presents findings from the project’s three components: A quantitative study of facilitation outcomes, a qualitative study of the facilitation process and its outcomes, and a qualitative study of facilitation skill transfer.

How Behavioral Healthcare Informatics Systems Interface with Medical Informatics Systems: A Work in Progress

Developments in the last decade show that behavioral healthcare informatics systems (BHISs) may interface effectively with medical informatics systems (MISs) and show promise for even more effective integration in the future. This chapter will provide examples of implementation techniques and current interface processes drawn primarily from developments in the Veterans Health Administration (VHA).