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Background: Integrating behavioral health services in primary care is challenging; a toolkit approach to practice implementation can help. A recent comparative effectiveness randomized clinical trial examined the impact of a toolkit for improving integration on outcomes for patients with multiple chronic conditions. Some aspects of behavioral health integration improved; patient-reported outcomes did not. This report evaluates the implementation strategy (Toolkit) using Proctor's (2011) implementation outcomes model., Methods: Using data from the 20 practices randomized to the active (toolkit strategy) arm (education, redesign workbooks, online learning community, remote coaching), we identified 23 measures from practice member surveys, coach interviews, reports, and field logs to assess Toolkit acceptability, appropriateness, feasibility, and fidelity. A practice survey score was high (met expectations) if its average was ≥ 4 on a scale 1-5; all other data were coded dichotomously, with high = 1., Results: Regarding acceptability, 74% (14) of practices had high scores for willingness of providers and staff to use the Toolkit and 68% (13) for quality improvement teams liking the Toolkit. For appropriateness, 95% (19) of practices had high scores for the structured process being a good match and 63% (12) for the Toolkit being a good match. Feasibility, measured by Toolkit prerequisites, was scored lower by site members at project end (e.g., provider leader available as champion: 53% of practices) compared to remote coaches observing practice teams (74%). For "do-ability," coaches rated feasibility lower for practices (e.g., completion of workbook activities: 32%) than the practice teams (68%). Fidelity was low as assessed across seven measures, with 50% to 78% of practices having high scores across the seven measures., Conclusions: Existing data from large trials can be used to describe implementation outcomes. The Toolkit was not implemented with fidelity in at least one quarter of the sites, despite being acceptable and appropriate, possibly due to low feasibility in the form of unmet prerequisites and Toolkit complexity. Variability in fidelity reflects the importance of implementation strategies that fit each organization, suggesting that further study on contextual factors and use of the Toolkit, as well as the relationship of Toolkit use and study outcomes, is needed., Trial Registration: ClinicalTrials.gov NCT02868983; date of registration: 08/15/2016., (© 2024. The Author(s).)

Background: Patients with chronic pain on opioids frequently experience loneliness, which is associated with poorer health outcomes and higher risk for opioid misuse and opioid use disorder. Given that almost half of opioids are prescribed in primary care, a critical need exists for the development and testing of interventions to reduce loneliness in primary care patients at risk for opioid misuse. Cognitive behavioral therapy and social prescribing have been shown to be efficacious in reducing loneliness and improving outcomes in other populations but have not been tested in patients at risk for substance use disorder. The overall objective of our study is to reduce opioid misuse and opioid use disorder by addressing loneliness in patients on long-term opioid therapy in real-world primary care settings., Methods: We will conduct a 3-arm pragmatic, randomized controlled trial to compare the effectiveness of two group-based, telehealth-delivered interventions with treatment as usual: (1) cognitive behavioral therapy to address maladaptive thought patterns and behaviors around social connection and (2) a social prescribing intervention to connect participants with social opportunities and develop supportive social networks. Our primary outcome is loneliness as measured by the UCLA Loneliness Scale and our dependent secondary outcome is opioid misuse as measured by the Common Opioid Misuse Measure. We will recruit 102 patients on long-term opioid therapy who screen positive for loneliness from 2 health care systems in Washington State. Implementation outcomes will be assessed using the RE-AIM framework., Discussion: Our study is innovative because we are targeting loneliness, an under-addressed but critical social risk factor that may prevent opioid misuse and use disorder in the setting where most patients are receiving their opioid prescriptions for chronic pain. If successful, the project will have a positive impact in reducing loneliness, reducing opioid misuse, improving function and preventing substance use disorder., Trial Registration: NCT06285032, issue date: February 28, 2024, original., (© 2024. The Author(s).)

Background: Differences in acute COVID-19 associated morbidity based on race, ethnicity, and gender have been well described; however, less is known about differences in subsequent longer term health-related quality of life and well-being., Methods: This prospective cohort study included symptomatic adults tested for SARS-CoV-2 who completed baseline and 3-month follow-up surveys. Using the PROMIS-29 tool, a validated measure of health and well-being, we compared outcomes at 3 months and change in outcomes from baseline to 3 months among groups with different races, ethnicities, and/or sexes., Results: Among 6044 participants, 4113 (3202 COVID +) were included. Among COVID + participants, compared to non-Hispanic White participants, Black participants had better PROMIS T-scores for cognitive function (3.6 [1.1, 6.2]) and fatigue (- 4.3 [- 6.6, - 2.0]) at 3 months and experienced more improvement in fatigue over 3 months (- 2.7 [- 4.7, - 0.8]). At 3 months, compared with males, females had worse PROMIS T-scores for cognitive function (- 4.1 [- 5.6, - 2.6]), physical function (- 2.1 [- 3.1, - 1.0]), social participation (- 2.8 [- 4.2, - 1.5]), anxiety (2.8 [1.5, 4.1]), fatigue (5.1 [3.7, 6.4]), and pain interference (2.0 [0.9, 3.2]). Females experienced less improvement in fatigue over 3 months (3.1 [2.0, 4.3]). Transgender/non-binary/other gender participants had worse 3-month scores in all domains except for sleep disturbance and pain interference., Conclusions: Three months after the initial COVID-19 infection, Black participants reported better cognitive function and fatigue, while females and other gender minoritized groups experienced lower well-being. Future studies are necessary to better understand how and why social constructs, specifically race, ethnicity, and gender, influence differences in COVID-19-related health outcomes. Trials Registration ClinicalTrials.gov Identifier: NCT04610515., (© 2024. The Author(s).)

While the early effects of the COVID-19 pandemic on the United States labor market are well-established, less is known about the long-term impact of SARS-CoV-2 infection and Long COVID on employment. To address this gap, we analyzed self-reported data from a prospective, national cohort study to estimate the effects of SARS-CoV-2 symptoms at three months post-infection on missed workdays and return to work. The analysis included 2,939 adults in the Innovative Support for Patients with SARS-CoV-2 Infections Registry (INSPIRE) study who tested positive for their initial SARS-CoV-2 infection at the time of enrollment, were employed before the pandemic, and completed a baseline and three-month electronic survey. At three months post-infection, 40.8% of participants reported at least one SARS-CoV-2 symptom and 9.6% of participants reported five or more SARS-CoV-2 symptoms. When asked about missed work due to their SARS-CoV-2 infection at three months, 7.2% of participants reported missing ≥10 workdays and 13.9% of participants reported not returning to work since their infection. At three months, participants with ≥5 symptoms had a higher adjusted odds ratio of missing ≥10 workdays (2.96, 95% CI 1.81-4.83) and not returning to work (2.44, 95% CI 1.58-3.76) compared to those with no symptoms. Prolonged SARS-CoV-2 symptoms were common, affecting 4-in-10 participants at three-months post-infection, and were associated with increased odds of work loss, most pronounced among adults with ≥5 symptoms at three months. Despite the end of the federal Public Health Emergency for COVID-19 and efforts to "return to normal", policymakers must consider the clinical and economic implications of the COVID-19 pandemic on people's employment status and work absenteeism, particularly as data characterizing the numerous health and well-being impacts of Long COVID continue to emerge. Improved understanding of risk factors for lost work time may guide efforts to support people in returning to work., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: AHI receives research grant funding from the University of Texas Southwestern Medical Center outside of the submitted work. AKV receives grants from the Agency for Healthcare Research and Quality and the SAEM Foundation outside the submitted work. ESS receives grant funding from the National Heart, Lung, and Blood Institute (R01HL151240), and the Patient Centered Outcomes Research Institute (HM-2022C2-28354). JCCM receives research grant funding from SAMHSA (1H79TI084428-01 and 1H79TI085981-01, PI LeSaint), FDA (75F40122C00116, PI Anderson), NIH-NINDS (U24NS129501, PI Rodriguez) outside the submitted work. JE is Editor-in-chief of the Adult Primary Care topics at UpToDate. KLR receives research grant funding from Abbott Diagnostics, DermTech, MeMed, Prenosis, Siemens Healthcare Diagnostics, PROCOVAXED funded by NIAID 1R01AI166967, and PREVENT funded by CDC U01CK00048 outside the submitted work. KNO receives research grant funding for PROCOVAXED funded by NIAID R01 AI166967, PI: Rodriguez outside the submitted work. MG receives grant funding from the Biomedical Advanced Research and Development Authority Research Grant, the Bill and Melinda Gates Foundation, and the Society of Directors of Research in Medical Education Grant outside the submitted work. MJH receives research grant funding from an Investigator Award from Merck, MISP 100099, PI: Hill outside the submitted work. The following authors have declared that no competing interests exist: HY, KAS, RAW. This does not alter our adherence to PLOS ONE policies on sharing data and materials., (Copyright: © 2024 Venkatesh et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Importance: Chronic symptoms reported following an infection with SARS-CoV-2, such as cognitive problems, overlap with symptoms included in the definition of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS)., Objective: To evaluate the prevalence of ME/CFS-like illness subsequent to acute SARS-CoV-2 infection, changes in ME/CFS symptoms through 12 months of follow-up, and the association of ME/CFS symptoms with SARS-CoV-2 test results at the acute infection-like index illness., Design, Setting, and Participants: This prospective, multisite, longitudinal cohort study (Innovative Support for Patients with SARS-CoV-2 Infections Registry [INSPIRE]) enrolled participants from December 11, 2020, to August 29, 2022. Participants were adults aged 18 to 64 years with acute symptoms suggestive of SARS-CoV-2 infection who received a US Food and Drug Administration-approved SARS-CoV-2 test at the time of illness and did not die or withdraw from the study by 3 months. Follow-up surveys were collected through February 28, 2023., Exposure: COVID-19 status (positive vs negative) at enrollment., Main Outcome and Measures: The main outcome was the weighted proportion of participants with ME/CFS-like illness based on the 2015 Institute of Medicine clinical case definition using self-reported symptoms., Results: A total of 4378 participants were included in the study. Most were female (3226 [68.1%]). Mean (SD) age was 37.8 (11.8) years. The survey completion rates ranged from 38.7% (3613 of 4738 participants) to 76.3% (1835 of 4738) and decreased over time. The weighted proportion of participants identified with ME/CFS-like illness did not change significantly at 3 through 12 months of follow-up and was similar in the COVID-19-positive (range, 2.8%-3.7%) and COVID-19-negative (range, 3.1%-4.5%) groups. Adjusted analyses revealed no significant difference in the odds of ME/CFS-like illness at any time point between COVID-19-positive and COVID-19-negative individuals (marginal odds ratio range, 0.84 [95% CI, 0.42-1.67] to 1.18 [95% CI, 0.55-2.51])., Conclusions and Relevance: In this prospective cohort study, there was no evidence that the proportion of participants with ME/CFS-like illness differed between those infected with SARS-CoV-2 vs those without SARS-CoV-2 infection up to 12 months after infection. A 3% to 4% prevalence of ME/CFS-like illness after an acute infection-like index illness would impose a high societal burden given the millions of persons infected with SARS-CoV-2.

The United States is facing a social isolation and loneliness crisis. In response, the US Surgeon General issued an advisory in May 2023 recommending actions that health care, community programs, and social services can take to collaboratively improve social connection. Primary care has a critical role to play in implementing the Surgeon General's recommendations. We present social isolation and loneliness as medical issues and highlight next steps for the primary care sector to combat this epidemic. Annals Early Access article., (© 2024 Annals of Family Medicine, Inc.)

Background: In response to the opioid crisis in the United States, population-level prescribing of opioids has been decreasing; there are concerns, however, that dose reductions are related to potential adverse events., Objective: Examine associations between opioid dose reductions and risk of 1-month potential adverse events (emergency department (ED) visits, opioid overdose, benzodiazepine prescription fill, all-cause mortality)., Design: This observational cohort study used electronic health record and claims data from eight United States health systems in a prescription opioid registry (Clinical Trials Network-0084). All opioid fills (excluding buprenorphine) between 1/1/2012 and 12/31/2018 were used to identify baseline periods with mean morphine milligram equivalents daily dose of  ≥ 50 during six consecutive months., Patients: We identified 60,040 non-cancer patients with  ≥ one 2-month dose reduction period (600,234 unique dose reduction periods)., Main Measures: Analyses examined associations between dose reduction levels (1- < 15%, 15- < 30%, 30- < 100%, 100% over 2 months) and potential adverse events in the month following a dose reduction using logistic regression analysis, adjusting for patient characteristics., Key Results: Overall, dose reduction periods involved mean reductions of 18.7%. Compared to reductions of 1- < 15%, dose reductions of 30- < 100% were associated with higher odds of ED visits (OR 1.14, 95% CI 1.10, 1.17), opioid overdose (OR 1.41, 95% CI 1.09-1.81), and all-cause mortality (OR 1.39, 95% CI 1.16-1.67), but lower odds of a benzodiazepine fill (OR 0.83, 95% CI 0.81-0.85). Dose reductions of 15- < 30%, compared to 1- < 15%, were associated with higher odds of ED visits (OR 1.08, 95% CI 1.05-1.11) and lower odds of a benzodiazepine fill (OR 0.93, 95% CI 0.92-0.95), but were not associated with opioid overdose and all-cause mortality., Conclusions: Larger reductions for patients on opioid therapy may raise risk of potential adverse events in the month after reduction and should be carefully monitored., (© 2023. The Author(s), under exclusive licence to Society of General Internal Medicine.)

Background: The COVID-19 pandemic disrupted how primary care patients with chronic pain received care. Our study sought to understand how long-term opioid therapy (LtOT) for chronic pain changed over the course of the pandemic overall and for different demographic subgroups., Methods: We used data from electronic health records of 64 primary care clinics across Washington state and Idaho to identify patients who had a chronic pain diagnosis and were receiving long-term opioid therapy. We defined 10-month periods in 2019 to 2021 as prepandemic, early pandemic and late pandemic and used generalized estimating equations analysis to compare across these time periods and demographic characteristics., Results: We found a proportional decrease in LtOT for chronic pain in the early months of the pandemic (OR = 0.94, P = .007 ) followed by an increase late pandemic (OR = 1.08, P = .002 ). Comparing late pandemic to prepandemic, identifying as Asian or Black, having fewer comorbidities, or living in an urban area were associated with higher likelihood of being prescribed LtOT., Discussion: The use of LtOT for chronic pain in primary care has increased from before to after the COVID-19 pandemic with racial/ethnic and geographic disparities. Future research is needed to understand these disparities in LtOT and their effect on patient outcomes., Competing Interests: Conflict of interest: None., (© Copyright 2024 by the American Board of Family Medicine.)

Objective: The Centers for Disease Control and Prevention's 2022 Clinical Practice Guideline for Prescribing Opioids for Pain cautioned that inflexible opioid prescription duration limits may harm patients. Information about the relationship between initial opioid prescription duration and a subsequent refill could inform prescribing policies and practices to optimize patient outcomes. We assessed the association between initial opioid duration and an opioid refill prescription., Methods: We conducted a retrospective cohort study of adults ≥19 years of age in 10 US health systems between 2013 and 2018 from outpatient care with a diagnosis for back pain without radiculopathy, back pain with radiculopathy, neck pain, joint pain, tendonitis/bursitis, mild musculoskeletal pain, severe musculoskeletal pain, urinary calculus, or headache. Generalized additive models were used to estimate the association between opioid days' supply and a refill prescription., Results: Overall, 220,797 patients were prescribed opioid analgesics upon an outpatient visit for pain. Nearly a quarter (23.5%) of the cohort received an opioid refill prescription during follow-up. The likelihood of a refill generally increased with initial duration for most pain diagnoses. About 1 to 3 fewer patients would receive a refill within 3 months for every 100 patients initially prescribed 3 vs. 7 days of opioids for most pain diagnoses. The lowest likelihood of refill was for a 1-day supply for all pain diagnoses, except for severe musculoskeletal pain (9 days' supply) and headache (3-4 days' supply)., Conclusions: Long-term prescription opioid use increased modestly with initial opioid prescription duration for most but not all pain diagnoses examined., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: together to conduct postmarketing studies required by the Food and Drug Administration that assess risks related to opioid analgesic use. Dr. Andrade has received research support on grants to the University of Massachusetts Chan Medical School from Pfizer, Inc., GlaxoSmithKline, and the Reagan-Udall Foundation, and consulting fees from Corevitas LLC. Dr. Binswanger receives royalties for educational content on the health of incarcerated persons from UpToDate. Ms. Rosa was substantially involved in the study, consistent with her role as Scientific Officer. She had no substantial involvement in the other cited grants., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Introduction: Data on ethnic and racial differences in symptoms and health-related impacts following SARS-CoV-2 infection are limited. We aimed to estimate the ethnic and racial differences in symptoms and health-related impacts 3 and 6 months after the first SARS-CoV-2 infection., Methods: Participants included adults with SARS-CoV-2 infection enrolled in a prospective multicenter US study between 12/11/2020 and 7/4/2022 as the primary cohort of interest, as well as a SARS-CoV-2-negative cohort to account for non-SARS-CoV-2-infection impacts, who completed enrollment and 3-month surveys ( N  = 3,161; 2,402 SARS-CoV-2-positive, 759 SARS-CoV-2-negative). Marginal odds ratios were estimated using GEE logistic regression for individual symptoms, health status, activity level, and missed work 3 and 6 months after COVID-19 illness, comparing each ethnicity or race to the referent group (non-Hispanic or white), adjusting for demographic factors, social determinants of health, substance use, pre-existing health conditions, SARS-CoV-2 infection status, COVID-19 vaccination status, and survey time point, with interactions between ethnicity or race and time point, ethnicity or race and SARS-CoV-2 infection status, and SARS-CoV-2 infection status and time point., Results: Following SARS-CoV-2 infection, the majority of symptoms were similar over time between ethnic and racial groups. At 3 months, Hispanic participants were more likely than non-Hispanic participants to report fair/poor health (OR: 1.94; 95%CI: 1.36-2.78) and reduced activity (somewhat less, OR: 1.47; 95%CI: 1.06-2.02; much less, OR: 2.23; 95%CI: 1.38-3.61). At 6 months, differences by ethnicity were not present. At 3 months, Other/Multiple race participants were more likely than white participants to report fair/poor health (OR: 1.90; 95% CI: 1.25-2.88), reduced activity (somewhat less, OR: 1.72; 95%CI: 1.21-2.46; much less, OR: 2.08; 95%CI: 1.18-3.65). At 6 months, Asian participants were more likely than white participants to report fair/poor health (OR: 1.88; 95%CI: 1.13-3.12); Black participants reported more missed work (OR, 2.83; 95%CI: 1.60-5.00); and Other/Multiple race participants reported more fair/poor health (OR: 1.83; 95%CI: 1.10-3.05), reduced activity (somewhat less, OR: 1.60; 95%CI: 1.02-2.51; much less, OR: 2.49; 95%CI: 1.40-4.44), and more missed work (OR: 2.25; 95%CI: 1.27-3.98)., Discussion: Awareness of ethnic and racial differences in outcomes following SARS-CoV-2 infection may inform clinical and public health efforts to advance health equity in long-term outcomes., Competing Interests: JGE is Editor in Chief of Adult Primary Care topics for UpToDate. MG reports grant funding from the Rush Center for Emerging Infectious Diseases Research Grant, Biomedical Advanced Research and Development Authority Research Grant, Emergency Medicine Foundation/Council of Residency Directors in Emergency Medicine Education Research Grant, Emergency Medicine: Reviews and Perspectives Medical Education Research Grant, University of Ottawa Department of Medicine Education Grant; and Society of Directors of Research in Medical Education Grant. KLR reports research grant funding from Abbott Diagnostics, DermTech, MeMed, Prenosis, and Siemens Healthcare Diagnostics. RMR reports research funding for PROCOVAXED funded by NIAID R01AI166967-01 (PI: Rodriquez). KK reports HECAP funded by RWJF (contract number: 79308 PI: Ansell); Chicago Department of Public Health Order 2020–4 COVID-19 Data Sharing for Patient Safety and Capacity Management funded by CDC (contract number: 6NU50CK000556-01-04 PI: Saldanha). GN reports funding through National Institutes of Health. PROCOVAXED Trial, Site PI. Centers for Disease Control and Prevention. Clinical Core, INSPIRE Registry, PI. Patient-Centered Outcomes Research Institute, Washington, DC. University of Washington PCORNet Expansion Award, Joint PI. Abiomed Inc., Danvers, MA. Emergency Care Core for Trial of Impella in Patients with STEMI and Cardiogenic Shock (RECOVER IV), PI. ZOLL Medical Corp., Chelmsford, MA, Multidimensional Study of Oxygenation in Early Post-Resuscitation (MOSER), PI. Vapotherm Inc., Exeter, NH. Vapotherm Device for Rapid Cooling Study (VOS), Co-PI. ZOLL Circulation Inc., San Jose, CA. Better Resuscitation with Supersaturated Oxygen (BASSO) Study, Co-PI. Powerful Medical Inc., Bratislava, Slovakia, US Validation Study of AI-Enhanced Diagnosis of Occluding Myocardial Infarction, PI. CPR Therapeutics Inc., Putney, VT. Consultant. Heartbeam Inc., Santa Clara, CA. Consultant. Invero Health LLC, Montville, NJ. Consultant. Kestra Medical Technologies Inc., Kirkland, WA. Consultant. Orixha Inc., Saint Cyr Au Mont d’Or, France. Consultant. BrainCool AB, Lund, Sweden. Consultant Patent for measurement of blood flow during CPR; non-provisional patent pending for blood flow measurement during CPR using signal gating; non-provisional patent pending for reperfusion-injury modifying device; all assigned to University of Washington. KNO reports research grant funding for PROCOVOXED funded by NIAID R01 AI166967 (PI: Rodriguez). The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 O’Laughlin, Klabbers, Ebna Mannan, Gentile, Geyer, Zheng, Yu, Li, Chan, Spatz, Wang, L’Hommedieu, Weinstein, Plumb, Gottlieb, Huebinger, Hagen, Elmore, Hill, Kelly, McDonald, Rising, Rodriguez, Venkatesh, Idris, Santangelo, Koo, Saydah, Nichol, Stephens and the INSPIRE Group.)

Purpose: Patient outcomes can improve when primary care and behavioral health providers use a collaborative system of care, but integrating these services is difficult. We tested the effectiveness of a practice intervention for improving patient outcomes by enhancing integrated behavioral health (IBH) activities., Methods: We conducted a pragmatic, cluster randomized controlled trial. The intervention combined practice redesign, quality improvement coaching, provider and staff education, and collaborative learning. At baseline and 2 years, staff at 42 primary care practices completed the Practice Integration Profile (PIP) as a measure of IBH. Adult patients with multiple chronic medical and behavioral conditions completed the Patient-Reported Outcomes Measurement Information System (PROMIS-29) survey. Primary outcomes were the change in 8 PROMIS-29 domain scores. Secondary outcomes included change in level of integration., Results: Intervention assignment had no effect on change in outcomes reported by 2,426 patients who completed both baseline and 2-year surveys. Practices assigned to the intervention improved PIP workflow scores but not PIP total scores. Baseline PIP total score was significantly associated with patient-reported function, independent of intervention. Active practices that completed intervention workbooks (n = 13) improved patient-reported outcomes and practice integration ( P ≤ .05) compared with other active practices (n = 7)., Conclusion: Intervention assignment had no effect on change in patient outcomes; however, we did observe improved patient outcomes among practices that entered the study with greater IBH. We also observed more improvement of integration and patient outcomes among active practices that completed the intervention compared to active practices that did not. Additional research is needed to understand how implementation efforts to enhance IBH can best reach patients., (© 2023 Annals of Family Medicine, Inc.)

Background and Objectives: Integrated behavioral health (BH) is becoming a preferred model of care for primary care because it improves patient outcomes and satisfaction. Little is known about whether residency practices are consistently modeling this preferred care model relative to real-world nonresidency practices. The study compared levels of BH integration, patient health outcomes, and satisfaction with care between residency practices and nonresidency practices with colocated BH providers., Methods: Baseline data were collected in 2018-2019 from 44 practices and their adult patients with chronic conditions participating in a cluster-randomized, pragmatic trial to improve BH integration. The sample included 18 (40.9%) residency and 26 (59.1%) nonresidency practices, with 1,817 (45.3%) patients from residency practices and 2,190 (54.7%) patients from nonresidency practices. Outcomes including BH integration levels (the Practice Integration Profile), patient health outcomes (the PROMIS-29), and patient satisfaction with care (the Consultation and Relational Empathy scale) were compared between residency and nonresidency practices using multivariate regression analyses., Results: No differences were found between BH integration levels, patient health outcomes, and patient satisfaction with care between residency and nonresidency practices. In a sample of primary care practices with colocated BH providers, residencies had BH integration and patient outcomes similar to real-world practices., Conclusions: Primary care practices with residency programs reported comparable levels of BH integration, patient health outcomes, and patient satisfaction compared to practices without residency programs. Both types of practices require interventions and resources to help them overcome challenges associated with dissemination of high levels of BH integration.

To further the understanding of post-COVID conditions, and provide a more nuanced description of symptom progression, resolution, emergence, and reemergence after SARS-CoV-2 infection or COVID-like illness, analysts examined data from the Innovative Support for Patients with SARS-CoV-2 Infections Registry (INSPIRE), a prospective multicenter cohort study. This report includes analysis of data on self-reported symptoms collected from 1,296 adults with COVID-like illness who were tested for SARS-CoV-2 using a Food and Drug Administration-approved polymerase chain reaction or antigen test at the time of enrollment and reported symptoms at 3-month intervals for 12 months. Prevalence of any symptom decreased substantially between baseline and the 3-month follow-up, from 98.4% to 48.2% for persons who received a positive SARS-CoV-2 test results (COVID test-positive participants) and from 88.2% to 36.6% for persons who received negative SARS-CoV-2 test results (COVID test-negative participants). Persistent symptoms decreased through 12 months; no difference between the groups was observed at 12 months (prevalence among COVID test-positive and COVID test-negative participants = 18.3% and 16.1%, respectively; p>0.05). Both groups reported symptoms that emerged or reemerged at 6, 9, and 12 months. Thus, these symptoms are not unique to COVID-19 or to post-COVID conditions. Awareness that symptoms might persist for up to 12 months, and that many symptoms might emerge or reemerge in the year after COVID-like illness, can assist health care providers in understanding the clinical signs and symptoms associated with post-COVID-like conditions., Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. Joann G. Elmore reports serving as editor-in-chief and receiving royalties from UpToDate, Inc. Michael Gottlieb reports grant support from the Society for Academic Emergency Medicine, the Society of Directors of Research in Medical Education, Rush Center for Emerging Infectious Diseases, Emergency Medicine: Reviews and Perspective, and the Emergency Medicine Foundation. Ahamed H. Idris reports travel support from the University of Michigan for attendance at Wolf Creek 17 conference, unpaid membership on the Stryker clinical advisory board, and unpaid volunteer chairmanship of the American Heart Association ethics writing group. Kelli N. O’Laughlin reports support from PROCOVAXED, from the National Institute on Allergy and Infectious Diseases, National Institutes of Health (NIH). Kristin Rising reports research grants from Abbott, Siemens diagnostics, DermTech, Ortho Diagnostics, NIH, and the Philadelphia Department of Public Health. Arjun K. Venkatesh reports grant support from the Society for Academic Emergency Medicine Foundation to study COVID-19 effects on hospitals. Robert A. Weinstein reports payments from UpToDate, Inc. for reviewing topics. No other potential conflicts of interest were disclosed.

Real-world data (RWD) like electronic health records (EHR) has great potential for secondary use by health systems and researchers. However, collected primarily for efficient health care, EHR data may not equitably represent local regions and populations, impacting the generalizability of insights learned from it. We assessed the geospatial representativeness of regions in a large health system EHR data using a spatial analysis workflow, which provides a data-driven way to quantify geospatial representation and identify adequately represented regions. We applied the workflow to investigate geospatial patterns of overweight/obesity and depression patients to find regional "hotspots" for potential targeted interventions. Our findings show the presence of geospatial bias in EHR and demonstrate the workflow to identify spatial clusters after adjusting for bias due to the geospatial representativeness. This work highlights the importance of evaluating geospatial representativeness in RWD to guide targeted deployment of limited healthcare resources and generate equitable real-world evidence., (©2023 AMIA - All rights reserved.)

Background: Most research on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variants focuses on initial symptomatology with limited longer-term data. We characterized prevalences of prolonged symptoms 3 months post-SARS-CoV-2 infection across 3 variant time-periods (pre-Delta, Delta, and Omicron)., Methods: This multicenter prospective cohort study of adults with acute illness tested for SARS-CoV-2 compared fatigue severity, fatigue symptoms, organ system-based symptoms, and ≥3 symptoms across variants among participants with a positive ("COVID-positive") or negative SARS-CoV-2 test ("COVID-negative") at 3 months after SARS-CoV-2 testing. Variant periods were defined by dates with ≥50% dominant strain. We performed multivariable logistic regression modeling to estimate independent effects of variants adjusting for sociodemographics, baseline health, and vaccine status., Results: The study included 2402 COVID-positive and 821 COVID-negative participants. Among COVID-positives, 463 (19.3%) were pre-Delta, 1198 (49.9%) Delta, and 741 (30.8%) Omicron. The pre-Delta COVID-positive cohort exhibited more prolonged severe fatigue (16.7% vs 11.5% vs 12.3%; P = .017) and presence of ≥3 prolonged symptoms (28.4% vs 21.7% vs 16.0%; P < .001) compared with the Delta and Omicron cohorts. No differences were seen in the COVID-negatives across time-periods. In multivariable models adjusted for vaccination, severe fatigue and odds of having ≥3 symptoms were no longer significant across variants., Conclusions: Prolonged symptoms following SARS-CoV-2 infection were more common among participants infected during pre-Delta than with Delta and Omicron; however, these differences were no longer significant after adjusting for vaccination status, suggesting a beneficial effect of vaccination on risk of long-term symptoms. Clinical Trials Registration. NCT04610515., Competing Interests: Potential conflicts of interest. M. G. reports the following institutional funding: Rush Center for Emerging Infectious Diseases Research Grant, Society for Academic Emergency Medicine Grant, Emergency Medicine Foundation/Council of Residency Directors in Emergency Medicine Education Research Grant, Emergency Medicine: Reviews and Perspectives Medical Education Research Grant, and University of Ottawa Department of Medicine Education Grant. E. S. S. receives grant funding from the National Institute on Minority Health and Health Disparities (U54MD010711-01), the US Food and Drug Administration (FDA) to support projects within the Yale–Mayo Clinic Center of Excellence in Regulatory Science and Innovation (U01FD005938), the National Institute of Biomedical Imaging and Bioengineering (R01 EB028106-01), and the National Heart, Lung, and Blood Institute (R01HL151240); and has received honorarium paid to author for a 1-day educational session from Regeneron. J. G. E. reports serving as Editor in Chief of Adult Primary Care topics for UpToDate. A. V. reports funding for coronavirus disease 2019 (COVID-19)–related studies from the Society of Academic Emergency Medicine Foundation Emerging Infectious Disease and Preparedness Grant, the Agency for Healthcare Research and Quality (R01 HS 28340-01), the FDA (ID: 75F40120C00174), and the Emergency Medicine Health Policy Institute/Emergency Medicine Foundation; grants or contracts from the American Board of Emergency Medicine National Academy of Medicine Fellowship, Centers for Medicare and Medicaid Services, National Institute on Drug Abuse, Moore Foundation, Genentech, and FORE Foundation; consulting fees from Liminal Sciences; payment for expert testimony from Salvi, Shostok & Pritchard; support for attending meetings and/or travel from the American College of Emergency Physician, and stock or stock options with Hyperfine Inc/Liminal Sciences. A. H. I. reports participation on a data and safety monitoring board (DSMB) or advisory board for Stryker, Inc. A. M. C. reports grants or contracts from the CDC, unrelated to this work. L. E. W. reports participation on a DSMB or advisory board for a diabetes project at University of Washington. R. R. reports a grant from the National Institute of Allergy and Infectious Diseases (R01 AI166967-01, all payments made to the University of California, San Francisco). R. A. W. reports consulting fees from UpToDate as a reviewer for infection control sections, and participation as unpaid member of a scientific advisory board for the European Clinical Research Alliance on Infectious Diseases Foundation. S. M. reports an NIH Institutional Training Grant (5KL2TR003981-02), not related to the submitted work. All other authors report no potential conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed., (© The Author(s) 2023. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Background: The prevalence, incidence, and interrelationships of persistent symptoms after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection vary. There are limited data on specific phenotypes of persistent symptoms. Using latent class analysis (LCA) modeling, we sought to identify whether specific phenotypes of COVID-19 were present 3 months and 6 months post-infection., Methods: This was a multicenter study of symptomatic adults tested for SARS-CoV-2 with prospectively collected data on general symptoms and fatigue-related symptoms up to 6 months postdiagnosis. Using LCA, we identified symptomatically homogenous groups among COVID-positive and COVID-negative participants at each time period for both general and fatigue-related symptoms., Results: Among 5963 baseline participants (4504 COVID-positive and 1459 COVID-negative), 4056 had 3-month and 2856 had 6-month data at the time of analysis. We identified 4 distinct phenotypes of post-COVID conditions (PCCs) at 3 and 6 months for both general and fatigue-related symptoms; minimal-symptom groups represented 70% of participants at 3 and 6 months. When compared with the COVID-negative cohort, COVID-positive participants had higher occurrence of loss of taste/smell and cognition problems. There was substantial class-switching over time; those in 1 symptom class at 3 months were equally likely to remain or enter a new phenotype at 6 months., Conclusions: We identified distinct classes of PCC phenotypes for general and fatigue-related symptoms. Most participants had minimal or no symptoms at 3 and 6 months of follow-up. Significant proportions of participants changed symptom groups over time, suggesting that symptoms present during the acute illness may differ from prolonged symptoms and that PCCs may have a more dynamic nature than previously recognized. Clinical Trials Registration.  NCT04610515., Competing Interests: Potential conflicts of interest. M. G. reports funding from the Rush Center for Emerging Infectious Diseases Research Grant, Emergency Medicine Foundation/Council of Residency Directors in Emergency Medicine Education Research Grant, Emergency Medicine: Reviews and Perspectives Medical Education Research Grant, University of Ottawa Department of Medicine Education Grant, and Society of Directors of Research in Medical Education Grant. E. S. S. receives grant funding from the National Institute on Minority Health and Health Disparities (U54MD010711-01), the US Food and Drug Administration to support projects within the Yale-Mayo Clinic Center of Excellence in Regulatory Science and Innovation (CERSI, U01FD005938), the National Institute of Biomedical Imaging and Bioengineering (R01EB028106-01), and the National Heart, Lung, and Blood Institute (R01HL151240). J. G. E. reports serving as Editor-in-Chief of Adult Primary Care topics for UpToDate. N. L. G. receives grant funding from the CDC (BAA75D301-20-75D30121C10207). A. V. reports funding for COVID-19–related studies from the Society of Academic Emergency Medicine Foundation Emerging Infectious Disease and Preparedness Grant, the Agency for Healthcare Research and Quality (R01 HS 28340-01), the Food and Drug Administration (ID: 75F40120C00174), and the Centers for Medicare and Medicaid Services. G. N. reports the following: funding for COVID-19–related studies from the National Institute of Allergy and Infectious Diseases (NIAID) (1R01AI66967), research funding from Abiomed, Vapotherm, and ZOLL Medical; consultant to CPR Therapeutics, Heartbeam Inc, Invero Health LLC, Kestra Medical Technologies, Orixha, and ZOLL Circulation; and reports a patent (Method for non-imaging ultrasound to measure blood flow during CPR) and nonprovisional patent (Method for modifying cell injury associated with reduced blood flow). K. N. O. reports funding for COVID-19–related studies from NIAID (1R01AI66967). K. L. R. reports funding for COVID-19–related studies from NIAID (1R01AI66967) and the Philadelphia Department of Public Health. All other authors report no potential conflicts., (© The Author(s) 2023. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Background: While prior work examining severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variants of concern focused on hospitalization and death, less is known about differences in clinical presentation. We compared the prevalence of acute symptoms across pre-Delta, Delta, and Omicron., Methods: We conducted an analysis of the Innovative Support for Patients with SARS-CoV-2 Infections Registry (INSPIRE), a cohort study enrolling symptomatic SARS-CoV-2-positive participants. We determined the association between the pre-Delta, Delta, and Omicron time periods and the prevalence of 21 coronavirus disease 2019 (COVID-19) acute symptoms., Results: We enrolled 4113 participants from December 2020 to June 2022. Pre-Delta vs Delta vs Omicron participants had increasing sore throat (40.9%, 54.6%, 70.6%; P < .001), cough (50.9%, 63.3%, 66.7%; P < .001), and runny noses (48.9%, 71.3%, 72.9%; P < .001). We observed reductions during Omicron in chest pain (31.1%, 24.2%, 20.9%; P < .001), shortness of breath (42.7%, 29.5%, 27.5%; P < .001), loss of taste (47.1%, 61.8%, 19.2%; P < .001), and loss of smell (47.5%, 55.6%, 20.0%; P < .001). After adjustment, those infected during Omicron had significantly higher odds of sore throat vs pre-Delta (odds ratio [OR], 2.76; 95% CI, 2.26-3.35) and Delta (OR, 1.96; 95% CI, 1.69-2.28)., Conclusions: Participants infected during Omicron were more likely to report symptoms of common respiratory viruses, such as sore throat, and less likely to report loss of smell and taste., Trial Registration: NCT04610515., Competing Interests: Potential conflicts of interest. Dr. Elmore reports serving as Editor in Chief of Adult Primary Care topics for UpToDate. Dr. Venkatesh reports funding for COVID-19-related studies from the Society of Academic Emergency Medicine Foundation Emerging Infectious Disease and Preparedness Grant, the Agency for Healthcare Research and Quality (R01 HS 28340-01) the Food and Drug Administration (ID: 75F40120C00174), and the Emergency Medicine Health Policy Institute/Emergency Medicine Foundation. Dr. Wang reports funding from CDC for research on N95 respirators. Dr. Gottlieb reports grant funding from the Rush Center for Emerging Infectious Diseases Research Grant, Emergency Medicine Foundation/Council of Residency Directors in Emergency Medicine Education Research Grant, Emergency Medicine: Reviews and Perspectives Medical Education Research Grant, University of Ottawa Department of Medicine Education Grant; and Society of Directors of Research in Medical Education Grant. Dr. Nichol reports the following: Vapotherm Inc, Exeter, NH- Research funding; ZOLL Medical, Chelmsford, MA- Research funding; Abiomed Inc., Danvers, MA- Consultant; CellPhire Inc., Rockville, MD- Consultant; CPR Therapeutics, Putney, VT- Consultant; ZOLL Circulation, San Jose, CA- Consultant; Patent- Method for non-imaging ultrasound to measure blood flow during CPR; Non-provisional patent- Method for modifying cell injury associated with reduced blood flow; Heartbeam Inc., Santa Clara, CA- Consultant; Invero Health, LLC., Montvale, NJ- Consultant; Orixha Inc., Saint Cyr Au Mont d’Or, France- Consultant; Kestra Medical Technologies, Kirkland, WA- Consultant; Medic One Foundation, Seattle, WA- Salary Support via Univ. Washington (UW). Dr. Elmore reports serving as Editor in Chief of Adult Primary Care topics for UpToDate. Dr. Venkatesh reports funding for COVID-19-related studies from the Society of Academic Emergency Medicine Foundation Emerging Infectious Disease and Preparedness Grant, the Agency for Healthcare Research and Quality (R01 HS 28340-01), the Food and Drug Administration (ID: 75F40120C00174), and the Emergency Medicine Health Policy Institute/Emergency Medicine Foundation. Dr. Wang reports funding from CDC for research on N95 respirators. All other authors report no potential conflicts., (© The Author(s) 2023. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Background: Long-term symptoms following severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection are a major concern, yet their prevalence is poorly understood., Methods: We conducted a prospective cohort study comparing adults with SARS-CoV-2 infection (coronavirus disease-positive [COVID+]) with adults who tested negative (COVID-), enrolled within 28 days of a Food and Drug Administration (FDA)-approved SARS-CoV-2 test result for active symptoms. Sociodemographic characteristics, symptoms of SARS-CoV-2 infection (assessed with the Centers for Disease Control and Prevention [CDC] Person Under Investigation Symptom List), and symptoms of post-infectious syndromes (ie, fatigue, sleep quality, muscle/joint pains, unrefreshing sleep, and dizziness/fainting, assessed with CDC Short Symptom Screener for myalgic encephalomyelitis/chronic fatigue syndrome) were assessed at baseline and 3 months via electronic surveys sent via text or email., Results: Among the first 1000 participants, 722 were COVID+ and 278 were COVID-. Mean age was 41.5 (SD 15.2); 66.3% were female, 13.4% were Black, and 15.3% were Hispanic. At baseline, SARS-CoV-2 symptoms were more common in the COVID+ group than the COVID- group. At 3 months, SARS-CoV-2 symptoms declined in both groups, although were more prevalent in the COVID+ group: upper respiratory symptoms/head/eyes/ears/nose/throat (HEENT; 37.3% vs 20.9%), constitutional (28.8% vs 19.4%), musculoskeletal (19.5% vs 14.7%), pulmonary (17.6% vs 12.2%), cardiovascular (10.0% vs 7.2%), and gastrointestinal (8.7% vs 8.3%); only 50.2% and 73.3% reported no symptoms at all. Symptoms of post-infectious syndromes were similarly prevalent among the COVID+ and COVID- groups at 3 months., Conclusions: Approximately half of COVID+ participants, as compared with one-quarter of COVID- participants, had at least 1 SARS-CoV-2 symptom at 3 months, highlighting the need for future work to distinguish long COVID., Clinical Trials Registration: NCT04610515., Competing Interests: Potential conflicts of interest . All authors: No potential conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest., (© The Author(s) 2022. Published by Oxford University Press on behalf of Infectious Diseases Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: Lung cancer is the most common cause of cancer-related death in the USA. While most patients are diagnosed following symptomatic presentation, no studies have compared symptoms and physical examination signs at or prior to diagnosis from electronic health records (EHRs) in the USA. We aimed to identify symptoms and signs in patients prior to diagnosis in EHR data., Design: Case-control study., Setting: Ambulatory care clinics at a large tertiary care academic health centre in the USA., Participants, Outcomes: We studied 698 primary lung cancer cases in adults diagnosed between 1 January 2012 and 31 December 2019, and 6841 controls matched by age, sex, smoking status and type of clinic. Coded and free-text data from the EHR were extracted from 2 years prior to diagnosis date for cases and index date for controls. Univariate and multivariable conditional logistic regression were used to identify symptoms and signs associated with lung cancer at time of diagnosis, and 1, 3, 6 and 12 months before the diagnosis/index dates., Results: Eleven symptoms and signs recorded during the study period were associated with a significantly higher chance of being a lung cancer case in multivariable analyses. Of these, seven were significantly associated with lung cancer 6 months prior to diagnosis: haemoptysis (OR 3.2, 95% CI 1.9 to 5.3), cough (OR 3.1, 95% CI 2.4 to 4.0), chest crackles or wheeze (OR 3.1, 95% CI 2.3 to 4.1), bone pain (OR 2.7, 95% CI 2.1 to 3.6), back pain (OR 2.5, 95% CI 1.9 to 3.2), weight loss (OR 2.1, 95% CI 1.5 to 2.8) and fatigue (OR 1.6, 95% CI 1.3 to 2.1)., Conclusions: Patients diagnosed with lung cancer appear to have symptoms and signs recorded in the EHR that distinguish them from similar matched patients in ambulatory care, often 6 months or more before diagnosis. These findings suggest opportunities to improve the diagnostic process for lung cancer., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

Integrating behavioral health into primary care can improve access to behavioral health and patient health outcomes. We used 2017-2021 American Board of Family Medicine continuing certificate examination registration questionnaire responses to determine the characteristics of family physicians who work collaboratively with behavioral health professionals. With a 100% response rate, 38.8% of 25,222 family physicians reported working collaboratively with behavioral health professionals, with those working in independently owned practices and in the South having substantially lower rates. Future research exploring these differences could help develop strategies to support family physicians implement integrated behavioral health to improve care for patients in these communities., (© 2023 Annals of Family Medicine, Inc.)

Professional practice guidelines (PPGs) are intended to promote a high level of professional practice and serve as an educational resource, providing pragmatic guidance in a clinical area for psychologists. Measurement-based care (MBC) is an evidence-based psychological practice with accumulating empirical support and alignment with patient-centered care. In connection with the American Psychological Association's Advisory Committee for Measurement-based Care and the Mental and Behavioral Health Registry, this article outlines various lines of support for the development and implementation of an MBC PPG. In addition to research evidence, we address the demonstrated need of this guideline across three domains: public benefit, professional guidance, and legal and regulatory issues. Consistent with the aspirational spirit of a PPG, this article proposes a draft PPG statement and highlights how an MBC PPG would improve service delivery, facilitate implementation of an evidence-based practice associated with symptom reduction, improved retention, and greater patient satisfaction, as well as create a framework that will better align changes in reimbursement models with patients' and providers' treatment goals. We also identify key future directions and critical gaps in MBC science and implementation that require attention. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Background: People of color (POC), especially those who also hold social identities associated with disadvantage (non-English-speaking, female, older, lower socioeconomic level), continue to be underserved in the health system, which can result in poorer care and worsened health outcomes. Most disparity research in traumatic brain injury (TBI) focuses on the impact of single factors, which misses the compounding effect of belonging to multiple historically marginalized groups., Objective: To examine the intersectional impact of multiple social identities vulnerable to systemic disadvantage following TBI on mortality, opioid usage during acute hospitalization, and discharge location., Methods: Retrospective observational design utilizing electronic health records merged with local trauma registry data. Patient groups were defined by race and ethnicity (POC or non-Hispanic White), age, sex, type of insurance, and primary language (English-speaking vs non-English-speaking). Latent class analysis (LCA) was performed to identify clusters of systemic disadvantage. Outcome measures were then assessed across latent classes and tested for differences., Results: Over an 8-year period, 10 809 admissions with TBI occurred (37% POC). LCA identified a 4-class model. Groups with more systemic disadvantage had higher rates of mortality. Classes with older populations had lower rates of opioid administration and were less likely to discharge to inpatient rehabilitation following acute care. Sensitivity analyses examining additional indicators of TBI severity demonstrated that the younger group with more systemic disadvantage had more severe TBI. Controlling for more indicators of TBI severity changed statistical significance in mortality for younger groups., Conclusion: Results demonstrate significant health inequities in the mortality and access to inpatient rehabilitation following TBI along with higher rates of severe injury in younger patients with more social disadvantages. While many inequities may be related to systemic racism, our findings suggested an additive, deleterious effect for patients who belonged to multiple historically disadvantaged groups. Further research is needed to understand the role of systemic disadvantage for individuals with TBI within the healthcare system., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Digital therapeutics are growing as a solution to manage pain for patients; yet, they are underused in primary care where over half of the patients with chronic pain seek care. Little is known about how to successfully engage primary care providers in recommending digital therapeutics to their patients. Exploring provider motivations in chronic pain management would potentially help to improve their engagement and inform the development of digital therapeutics., Objective: This study examined primary care providers' motivations for chronic pain management, including their strategies and challenges, to inform the future development of chronic pain-related digital therapeutics tailored to primary care settings., Methods: We conducted qualitative semistructured interviews with health care providers recruited from 3 primary care clinics in Washington and 1 clinic in Colorado between July and October 2021. The sample (N=11) included 7 primary care physicians, 2 behavioral health providers, 1 physician assistant, and 1 nurse. Most providers worked in clinics affiliated with urban academic health systems. Guided by the human-centered design approach and Christensen's Job-to-be-Done framework, we asked providers their goals and priorities in chronic pain management, their experiences with challenges and strategies used to care for patients, and their perceptions of applying digital therapeutics in clinical practice. Transcripts were analyzed using a thematic analysis approach., Results: We found that primary care providers were motivated but challenged to strengthen the patient-provider alliance, provide team-based care, track and monitor patients' progress, and address social determinants of health in chronic pain management. Specifically, providers desired additional resources to improve patient-centered communication, pain education and counseling, and goal setting with patients. Providers also requested greater accessibility to multidisciplinary care team consultations and nonpharmacological pain treatments. When managing chronic pain at the population level, providers need infrastructure and systems to systematically track and monitor patients' pain and provide wraparound health and social services for underserved patients. Recommendations on digital therapeutic features that might address provider challenges in achieving these motivations were discussed., Conclusions: Given the findings, to engage primary care providers, digital therapeutics for chronic pain management need to strengthen the patient-provider alliance, increase access to nonpharmacological treatment options, support population health tracking and management, and provide equitable reach. Leveraging digital therapeutics in a feasible, appropriate, and acceptable way to aid primary care providers in chronic pain management may require multimodal features that address provider motivations at an individual care and clinic or system level., (©Kris Pui Kwan Ma, Kari A Stephens, Rachel E Geyer, Maria G Prado, Brenda L Mollis, Susan M Zbikowski, Deanna Waters, Jo Masterson, Ying Zhang. Originally published in JMIR Formative Research (https://formative.jmir.org), 03.02.2023.)

Introduction: Integrating behavioral health in primary care improves quality of care and outcomes for patients with comorbid conditions. Shortage of a trained behavioral health workforce limits adoption. Professional psychology training programs contribute to recruitment, retention, and development of skilled providers, who value and deliver behavioral health services in primary care. This study interviewed a cohort of established psychology training programs in real-world, state-wide clinical primary care settings and identified their strategies and challenges with teaching practices and program resources that impact the robust quality of training., Method: Between December 2020 and March 2021, we conducted semistructured interviews with 12 licensed psychologists who oversaw nine integrated primary care psychology training programs at the internship and postdoctoral levels across Washington State. Data were analyzed using a thematic approach., Results: Programs taught psychology trainees about integrated primary care via extensive onboarding, modeling and shadowing, structured learning environment, interprofessional education opportunities, flexible and cross-disciplinary supervision, and a psychologically safe space. Teaching challenges included balancing scheduled and curbside supervision, pivoting to telehealth, and aligning trainee expectations and program requirements. Training programs were funded through different and multiple sources, but most lacked a stable funding mechanism, compounded by barriers for psychology trainees to bill for services, a lack of control over organization's budgeting decisions, and instability in funding renewal., Conclusion: Synergistic support from program, organization, and system/policy levels are needed to align teaching activities with clinical practice environments and invest in the growth and sustainability of psychology training programs on integrated primary care. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

The diagnosis of lung cancer in ambulatory settings is often challenging due to non-specific clinical presentation, but there are currently no clinical quality measures (CQMs) in the United States used to identify areas for practice improvement in diagnosis. We describe the pre-diagnostic time intervals among a retrospective cohort of 711 patients identified with primary lung cancer from 2012-2019 from ambulatory care clinics in Seattle, Washington USA. Electronic health record data were extracted for two years prior to diagnosis, and Natural Language Processing (NLP) applied to identify symptoms/signs from free text clinical fields. Time points were defined for initial symptomatic presentation, chest imaging, specialist consultation, diagnostic confirmation, and treatment initiation. Median and interquartile ranges (IQR) were calculated for intervals spanning these time points. The mean age of the cohort was 67.3 years, 54.1% had Stage III or IV disease and the majority were diagnosed after clinical presentation (94.5%) rather than screening (5.5%). Median intervals from first recorded symptoms/signs to diagnosis was 570 days (IQR 273-691), from chest CT or chest X-ray imaging to diagnosis 43 days (IQR 11-240), specialist consultation to diagnosis 72 days (IQR 13-456), and from diagnosis to treatment initiation 7 days (IQR 0-36). Symptoms/signs associated with lung cancer can be identified over a year prior to diagnosis using NLP, highlighting the need for CQMs to improve timeliness of diagnosis.

White matter lesions (WML) have been linked to cognitive decline in aging as well as in Alzheimer's disease. While hypoperfusion is frequently considered a cause of WMLs due to the resulting reduction in oxygen availability to brain tissue, such reductions could also be caused by impaired oxygen exchange. Here, we tested the hypothesis that venous hyperintense signal (VHS) in arterial spin labeling (ASL) magnetic resonance imaging (MRI) may represent a marker of impaired oxygen extraction in aging older adults. In participants aged 60-80 years (n = 30), we measured cerebral blood flow and VHS with arterial spin labeling, maximum oxygen extraction fraction (OEF max ) with dynamic susceptibility contrast, and WML volume with T 1 -weighted MRI. We found a significant interaction between OEF max and VHS presence on WML volume ( p  = 0.02), where lower OEF max was associated with higher WML volume in participants with VHS, and higher OEF max was associated with higher WML volume in participants without VHS. These results indicate that VHS in perfusion-weighted ASL data may represent a distinct cerebrovascular aging pattern involving oxygen extraction inefficiency as well as hypoperfusion.

Background and Aim: There is no gold-standard and considerable heterogeneity in outcome measures used to evaluate treatments for opioid use disorder (OUD) along the opioid treatment cascade. The aim of this study was to develop the US National Institute on Drug Abuse (NIDA) National Drug Abuse Treatment Clinical Trials Network (CTN) opioid use disorder core outcomes set (OUD-COS)., Design: Four-round, e-Delphi expert panel consensus study and plenary research group discussion and targeted consultation., Setting: United States., Participants: A panel of 25 members including clinical practitioners, clinical researchers and administrative staff from the CTN, the network's affiliated clinical and community sites and the NIDA Centre for the CTN., Measurements: From a pool of 24 candidate items in four domains (biomedical/disease status; behaviors, symptoms and functioning; opioid treatment cascade; and morbidity and mortality), the panel completed an on-line questionnaire to rank items with defined specification on a 9-point scale for importance, with a standard 70% consensus criterion., Findings: After the fourth round of the questionnaire and subsequent discussion, consensus was reached for five outcomes: two patient-reported (global impression of improvement and incident non-fatal overdose); one clinician-reported (illicit/non-medical drug toxicology); and two from administrative records (duration of treatment and fatal opioid poisoning)., Conclusions: An e-Delphi consensus study has produced the US National Institute on Drug Abuse (NIDA) National Drug Abuse Treatment Clinical Trials Network opioid use disorder core outcomes set (version 1) for opioid use disorder treatment efficacy and effectiveness research., (© 2022 The Authors. Addiction published by John Wiley & Sons Ltd on behalf of Society for the Study of Addiction.)

Recent value-based payment reforms in the U.S. called for empirical data on how primary care practices of varying characteristics fund their integrated behavioral health services. To describe payment strategies used by U.S. primary care practices to fund behavioral health integration and compare strategies between practices with and without hospital affiliation.Baseline data were used and collected from 44 practices participating in a cluster-randomized, pragmatic trial of behavioral health integration. Data included practice characteristics and payment strategies-fee-for-service payment, pay-for-performance incentives, grants, and graduate medical education funds. Descriptive and comparative analyses using Fisher's exact tests and independent T-tests were conducted. The sample had 26 (59.1%) hospital-affiliated (hospital/health system-owned, academic medical centers and hospital-affiliated practices) and 18 (40.9%) non-hospital-affiliated practices (community health centers/federally qualified health centers and privately-owned practices). Most practices (88.6%) received payments through fee-for-service; 63.6% received pay-for-performance incentives; 31.8% received grant funds. Collaborative Care Management billing (CPT) codes were used in six (13.6%) practices. Over half (53.8%) of hospital-affiliated practices funded their behavioral health services through fee-for-service and pay-for-performance incentives only, as opposed to two-thirds (66.7%) of non-hospital-affiliated practices required additional support from grants and/or general medical education funds. Primary care practices support behavioral health integration through diverse payment strategies. More hospital-affiliated practices compared to non-hospital-affiliated practices funded integrated behavioral health services through fee-for-service and pay-for-performance incentives. Practices without hospital affiliation relied on multiple funding streams including grants and/or general medical education funds, suggesting their approach to financial sustainment may be more precarious or challenging, compared to hospital-affiliated practices., (© Society of Behavioral Medicine 2022. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: Develop and implement a prescription opioid registry in 10 diverse health systems across the US and describe trends in prescribed opioids between 2012 and 2018., Materials and Methods: Using electronic health record and claims data, we identified patients who had an outpatient fill for any prescription opioid, and/or an opioid use disorder diagnosis, between January 1, 2012 and December 31, 2018. The registry contains distributed files of prescription opioids, benzodiazepines and other select medications, opioid antagonists, clinical diagnoses, procedures, health services utilization, and health plan membership. Rates of outpatient opioid fills over the study period, standardized to health system demographic distributions, are described by age, gender, and race/ethnicity among members without cancer., Results: The registry includes 6 249 710 patients and over 40 million outpatient opioid fills. For the combined registry population, opioid fills declined from a high of 0.718 per member-year in 2013 to 0.478 in 2018, and morphine milligram equivalents (MMEs) per fill declined from 985 MMEs per fill in 2012 to 758 MMEs in 2018. MMEs per member declined from 692 MMEs per member in 2012 to 362 MMEs per member in 2018., Conclusion: This study established a population-based opioid registry across 10 diverse health systems that can be used to address questions related to opioid use. Initial analyses showed large reductions in overall opioid use per member among the combined health systems. The registry will be used in future studies to answer a broad range of other critical public health issues relating to prescription opioid use., (© The Author(s) 2022. Published by Oxford University Press on behalf of the American Medical Informatics Association.)

Background: Reports on medium and long-term sequelae of SARS-CoV-2 infections largely lack quantification of incidence and relative risk. We describe the rationale and methods of the Innovative Support for Patients with SARS-CoV-2 Registry (INSPIRE) that combines patient-reported outcomes with data from digital health records to understand predictors and impacts of SARS-CoV-2 infection., Methods: INSPIRE is a prospective, multicenter, longitudinal study of individuals with symptoms of SARS-CoV-2 infection in eight regions across the US. Adults are eligible for enrollment if they are fluent in English or Spanish, reported symptoms suggestive of acute SARS-CoV-2 infection, and if they are within 42 days of having a SARS-CoV-2 viral test (i.e., nucleic acid amplification test or antigen test), regardless of test results. Recruitment occurs in-person, by phone or email, and through online advertisement. A secure online platform is used to facilitate the collation of consent-related materials, digital health records, and responses to self-administered surveys. Participants are followed for up to 18 months, with patient-reported outcomes collected every three months via survey and linked to concurrent digital health data; follow-up includes no in-person involvement. Our planned enrollment is 4,800 participants, including 2,400 SARS-CoV-2 positive and 2,400 SARS-CoV-2 negative participants (as a concurrent comparison group). These data will allow assessment of longitudinal outcomes from SARS-CoV-2 infection and comparison of the relative risk of outcomes in individuals with and without infection. Patient-reported outcomes include self-reported health function and status, as well as clinical outcomes including health system encounters and new diagnoses., Results: Participating sites obtained institutional review board approval. Enrollment and follow-up are ongoing., Conclusions: This study will characterize medium and long-term sequelae of SARS-CoV-2 infection among a diverse population, predictors of sequelae, and their relative risk compared to persons with similar symptomatology but without SARS-CoV-2 infection. These data may inform clinical interventions for individuals with sequelae of SARS-CoV-2 infection., Competing Interests: I read the journal’s policy and the authors of this manuscript have the following competing interests: HMK is co-founder for Hugo Health; he is not employed by Hugo Health and he receives no salary support from Hugo Health. Hugo Health is a vendor to support INSPIRE study operations and is not the funder of this study or the subject of the investigation. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Primary care has increasingly adopted integrated behavioral health (IBH) practices to enhance overall care. The IBH Cross-Model Framework clarifies the core processes and structures of IBH, but little is known about how practices vary in the implementation of these processes and structures. This study aimed to describe clusters of clinics using the IBH Cross-Model Framework for a large sample of primary care clinics, as well as contextual variables associated with differences in implementation. Primary care clinics (N = 102) in Minnesota reported their level of implementation across 18 different components of IBH via the site self-assessment (SSA). The components were mapped to all five principles and four of the nine structures of the IBH Cross-Model Framework. latent class analysis was used to identify unique clusters of IBH components from the SSA across the IBH Cross-Model Framework's processes and structures. Latent classes were then regressed onto context variables. A four-class model was determined to be the best fit: Low IBH (39.6%), Structural IBH (7.9%), Partial IBH (29.4%), and Strong IBH (23.1%). Partial IBH clinics were more urban than the other three classes, lower in SES risk than Structural IBH clinics, and located in smaller organizations than Strong IBH clinics. There were no differences between classes in race/ethnicity of the clinic area or practice size. Four groups of IBH implementation were identified representing unique profiles of integration. These clusters may represent patterns of community-based implementation of IBH that indicate easier and more challenging aspects of IBH implementation., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

We characterize cerebral sensitivity across the entire adult human head for diffuse correlation spectroscopy, an optical technique increasingly used for bedside cerebral perfusion monitoring. Sixteen subject-specific magnetic resonance imaging-derived head models were used to identify high sensitivity regions by running Monte Carlo light propagation simulations at over eight hundred uniformly distributed locations on the head. Significant spatial variations in cerebral sensitivity, consistent across subjects, were found. We also identified correlates of such differences suitable for real-time assessment. These variations can be largely attributed to changes in extracerebral thickness and should be taken into account to optimize probe placement in experimental settings., Competing Interests: MAF has a financial interest in 149 Medical, Inc., a company developing DCS technology for assessing and monitoring cerebral blood flow in newborn infants. MAF’s interests were reviewed and are managed by Massachusetts General Hospital and Mass General Brigham in accordance with their conflict of interest policies (I)., (© 2022 Optica Publishing Group under the terms of the Optica Open Access Publishing Agreement.)

Background: Mood disorders (MDS) are a type of mental health illness that effects millions of people in the United States. Early prediction of MDS can give providers greater opportunity to treat these disorders. We hypothesized that longitudinal cardiovascular health (CVH) measurements would be informative for MDS prediction., Methods: To test this hypothesis, the American Heart Association's Guideline Advantage (TGA) dataset was used, which contained longitudinal EHR from 70 outpatient clinics. The statistical analysis and machine learning models were employed to identify the associations of the MDS and the longitudinal CVH metrics and other confounding factors., Results: Patients diagnosed with MDS consistently had a higher proportion of poor CVH compared to patients without MDS, with the largest difference between groups for Body mass index (BMI) and Smoking. Race and gender were associated with status of CVH metrics. Approximate 46% female patients with MDS had a poor hemoglobin A1C compared to 44% of those without MDS; 62% of those with MDS had poor BMI compared to 47% of those without MDS; 59% of those with MDS had poor blood pressure (BP) compared to 43% of those without MDS; and 43% of those with MDS were current smokers compared to 17% of those without MDS., Conclusions: Women and ethnoracial minorities with poor cardiovascular health measures were associated with a higher risk of development of MDS, which indicated the high utility for using routine medical records data collected in care to improve detection and treatment for MDS among patients with poor CVH., (© 2021. The Author(s).)

Background: Occupational burnout is a major concern for personal well-being and patient care. We examined burnout among primary care providers (PCPs), medical residents, behavioral health providers (BHPs), nurses, and other clinical and nonclinical primary care team members., Methods: This was a cross-sectional study, nested within a larger randomized trial. Participants completed a validated 9-item burnout measure with 3 domains: depersonalization, emotional exhaustion, and personal accomplishment. Multivariable multilevel linear regression with a random intercept for each practice was used to determine mean differences in burnout across professional roles., Results: Overall burnout rates varied by professional role: PCPs 70%, medical residents 89%, BHPs 59%, nurses 66%, other clinicians 68%, and nonclinical professionals 70%. Compared with nonclinical professionals, residents experienced more burnout in more domains, followed by PCPs. PCPs, residents, and nurses reported significantly worse depersonalization and exhaustion scores. Nonclinical professionals had worse accomplishment scores than all clinical professionals except for residents. This study revealed moderate-to-high levels of burnout among primary care professionals., Discussion: Clinicians may be experiencing aspects of burnout more intensely than their nonclinical colleagues, and this may be most true for residents and PCPs. Based on these variations, interventions to mitigate burnout may need to be tailored by professional role., Competing Interests: Conflict of interest: None., (© Copyright 2021 by the American Board of Family Medicine.)

Arterial spin labeling (ASL) magnetic resonance imaging (MRI) has become a popular approach for studying cerebral hemodynamics in a range of disorders and has recently been included as part of the Human Connectome Project-Aging (HCP-A). Due to the high spatial resolution and multiple post-labeling delays, ASL data from HCP-A holds promise for localization of hemodynamic signals not only in gray matter but also in white matter. However, gleaning information about white matter hemodynamics with ASL is challenging due in part to longer blood arrival times in white matter compared to gray matter. In this work, we present an analytical approach for deriving measures of cerebral blood flow (CBF) and arterial transit times (ATT) from the ASL data from HCP-A and report on gray and white matter hemodynamics in a large cohort (n = 234) of typically aging adults (age 36-90 years). Pseudo-continuous ASL data were acquired with labeling duration = 1500 ms and five post-labeling delays = 200 ms, 700 ms, 1200, 1700 ms, and 2200 ms. ATT values were first calculated on a voxel-wise basis through normalized cross-correlation analysis of the acquired signal time course in that voxel and an expected time course based on an acquisition-specific Bloch simulation. CBF values were calculated using a two-compartment model and with age-appropriate blood water longitudinal relaxation times. Using this approach, we found that white matter CBF reduces (ρ = 0.39) and white matter ATT elongates (ρ = 0.42) with increasing age (p < 0.001). In addition, CBF is lower and ATTs are longer in white matter compared to gray matter across the adult lifespan (Wilcoxon signed-rank tests; p < 0.001). We also found sex differences with females exhibiting shorter white matter ATTs than males, independently of age (Wilcoxon rank-sum test; p < 0.001). Finally, we have shown that CBF and ATT values are spatially heterogeneous, with significant differences in cortical versus subcortical gray matter and juxtacortical versus periventricular white matter. These results serve as a characterization of normative physiology across the human lifespan against which hemodynamic impairment due to cerebrovascular or neurodegenerative diseases could be compared in future studies., (Copyright © 2021. Published by Elsevier Inc.)

Background: Chronic diseases that drive morbidity, mortality, and health care costs are largely influenced by human behavior. Behavioral health conditions such as anxiety, depression, and substance use disorders can often be effectively managed. The majority of patients in need of behavioral health care are seen in primary care, which often has difficulty responding. Some primary care practices are providing integrated behavioral health care (IBH), where primary care and behavioral health providers work together, in one location, using a team-based approach. Research suggests there may be an association between IBH and improved patient outcomes. However, it is often difficult for practices to achieve high levels of integration. The Integrating Behavioral Health and Primary Care study responds to this need by testing the effectiveness of a comprehensive practice-level intervention designed to improve outcomes in patients with multiple chronic medical and behavioral health conditions by increasing the practice's degree of behavioral health integration., Methods: Forty-five primary care practices, with existing onsite behavioral health care, will be recruited for this study. Forty-three practices will be randomized to the intervention or usual care arm, while 2 practices will be considered "Vanguard" (pilot) practices for developing the intervention. The intervention is a 24-month supported practice change process including an online curriculum, a practice redesign and implementation workbook, remote quality improvement coaching services, and an online learning community. Each practice's degree of behavioral health integration will be measured using the Practice Integration Profile. Approximately 75 patients with both chronic medical and behavioral health conditions from each practice will be asked to complete a series of surveys to measure patient-centered outcomes. Change in practice degree of behavioral health integration and patient-centered outcomes will be compared between the two groups. Practice-level case studies will be conducted to better understand the contextual factors influencing integration., Discussion: As primary care practices are encouraged to provide IBH services, evidence-based interventions to increase practice integration will be needed. This study will demonstrate the effectiveness of one such intervention in a pragmatic, real-world setting., Trial Registration: ClinicalTrials.gov NCT02868983 . Registered on August 16, 2016.

Objective: Information gaps that accompany hurricanes and floods limit researchers' ability to determine the impact of disasters on population health. Defining key use cases for sharing complex disaster data with research communities and facilitators, and barriers to doing so are key to promoting population health research for disaster recovery., Materials and Methods: We conducted a mixed-methods needs assessment with 15 population health researchers using interviews and card sorting. Interviews examined researchers' information needs by soliciting barriers and facilitators in the context of their expertise and research practices. Card sorting ranked priority use cases for disaster preparedness., Results: Seven barriers and 6 facilitators emerged from interviews. Barriers to collaborative research included process limitations, collaboration dynamics, and perception of research importance. Barriers to data and technology adoption included data gaps, limitations in information quality, transparency issues, and difficulty to learn. Facilitators to collaborative research included collaborative engagement and human resource processes. Facilitators to data and technology adoption included situation awareness, data quality considerations, adopting community standards, and attractive to learn. Card sorting prioritized 15 use cases and identified 30 additional information needs for population health research in disaster preparedness., Conclusions: Population health researchers experience barriers to collaboration and adoption of data and technology that contribute to information gaps and limit disaster preparedness. The priority use cases we identified can help address information gaps by informing the design of supportive research tools and practices for disaster preparedness. Supportive tools should include information on data collection practices, quality assurance, and education resources usable during failures in electric or telecommunications systems., (© The Author(s) 2020. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: A lack of consensus on the optimal outcome measures to assess the efficacy and effectiveness of interventions for the treatment of opioid use disorder (OUD) has hampered the pooling of research data for evidence synthesis and clinical guidelines. A core outcome set (COS) is a minimum set of outcome measures that are recommended for all studies of a particular condition. The National Drug Abuse Treatment Clinical Trials Network (CTN) Core Outcome Set for OUD (COS-OUD) is a development study to identify core constructs, meaningful outcomes, and their optimal measurement for all efficacy and effectiveness studies of OUD treatment and service delivery., Methods/design: Overseen by an expert workgroup, a modified, stepwise, e-Delphi methodology will be used to gain consensus among a panel of clinical practitioners and researchers involved in the treatment of OUD, who are members of the CTN. Sequential rounds of anonymous, online questionnaires will be used to identify, rate the importance of, and refine a core outcome set. A consensus threshold will be achieved if at least 70% of the panel rate the measure as critical for inclusion in the COS-OUD. Where consensus is not reached or there are suggestions for new measures, these will be brought forward to a further round of review prior to a consensus meeting. Products from this study will be communicated via peer-reviewed scientific journals and conferences., Discussion: This initiative will develop a COS for OUD intervention trials, treatment studies, and service delivery and will support the pooling of research and clinical practice data and efforts to develop measurement-based care within the OUD treatment cascade., Trial Registration: http://www.comet-initiative.org/Studies/Details/1579.

Significance: Contamination of diffuse correlation spectroscopy (DCS) measurements of cerebral blood flow (CBF) due to systemic physiology remains a significant challenge in the clinical translation of DCS for neuromonitoring. Tunable, multi-layer Monte Carlo-based (MC) light transport models have the potential to remove extracerebral flow cross-talk in cerebral blood flow index ( CBF i ) estimates. Aim: We explore the effectiveness of MC DCS models in recovering accurate CBF i changes in the presence of strong systemic physiology variations during a hypercapnia maneuver. Approach: Multi-layer slab and head-like realistic (curved) geometries were used to run MC simulations of photon propagation through the head. The simulation data were post-processed into models with variable extracerebral thicknesses and used to fit DCS multi-distance intensity autocorrelation measurements to estimate CBF i timecourses. The results of the MC CBF i values from a set of human subject hypercapnia sessions were compared with CBF i values estimated using a semi-infinite analytical model, as commonly used in the field. Results: Group averages indicate a gradual systemic increase in blood flow following a different temporal profile versus the expected rapid CBF response. Optimized MC models, guided by several intrinsic criteria and a pressure modulation maneuver, were able to more effectively separate CBF i changes from scalp blood flow influence than the analytical fitting, which assumed a homogeneous medium. Three-layer models performed better than two-layer ones; slab and curved models achieved largely similar results, though curved geometries were closer to physiological layer thicknesses. Conclusion: Three-layer, adjustable MC models can be useful in separating distinct changes in scalp and brain blood flow. Pressure modulation, along with reasonable estimates of physiological parameters, can help direct the choice of appropriate layer thicknesses in MC models., (© 2021 The Authors.)

Purpose: Primary care is challenged with safely prescribing opioids for patients with chronic noncancer pain (CNCP), specifically to address risks for overdose, opioid use disorder, and death. We identify sociotechnical challenges, approaches, and recommendations in primary care to effectively track and monitor patients on long-term opioid therapy, a key component for supporting adoption of opioid prescribing guidelines., Methods: We examined qualitative data (field notes and postintervention interview and focus group transcripts) from 6 rural and rural-serving primary care organizations with 20 clinic locations enrolled in a study evaluating a practice redesign program to improve opioid medication management for CNCP patients. Two independent researchers used content analysis to categorize data into key themes to develop an understanding of sociotechnical factors critical to creating and implementing an approach to tracking and monitoring of patients on long-term opioid therapy in primary care practices., Results: Four factors were critical to developing a tracking and monitoring system. For each we describe common challenges and approaches used by the clinics to overcome then. The first factor, buy-in and participation, was essential for accomplishing the other 3. The other factors occurred sequentially: 1) cohort identification-finding the right patients, 2) data collection and extraction-tracking the right data, and 3) data use-monitoring patients and adjusting care processes., Conclusions: We identified common challenges and approaches to tracking and monitoring patients using long-term opioid therapy for CNCP in primary care. Based on these findings we provide recommendations to build capacity for tracking and monitoring for organizations that are engaged in improving safe opioid-prescribing practices for CNCP in primary care., Competing Interests: Conflict of interest: None., (© Copyright 2021 by the American Board of Family Medicine.)

Background and Purpose: Cerebral white matter signal abnormalities (WMSAs) are a significant radiological marker associated with brain and vascular aging. However, understanding their clinical impact is limited because of their pathobiological heterogeneity. We determined whether use of robust reliable automated procedures can distinguish WMSA classes with different clinical consequences., Methods: Data from generally healthy participants aged >50 years with moderate or greater WMSA were selected from the Human Connectome Project-Aging (n=130). WMSAs were segmented on T1 imaging. Features extracted from WMSA included total and regional volume, number of discontinuous clusters, size of noncontiguous lesion, contrast of lesion intensity relative to surrounding normal appearing tissue using a fully automated procedure. Hierarchical clustering was used to classify individuals into distinct classes of WMSA. Radiological and clinical variability was evaluated across the individual WMSA classes., Results: Class I was characterized by multiple, small, lower-contrast lesions predominantly in the deep WM; class II by large, confluent lesions in the periventricular WM; and class III by higher-contrast lesions restricted to the juxtaventricular WM. Class II was associated with lower myelin content than the other 2 classes. Class II was more prevalent in older subjects and was associated with a higher prevalence of hypertension and lower physical activity levels. Poor sleep quality was associated with a greater risk of class I., Conclusions: We classified heterogeneous subsets of cerebral white matter lesions into distinct classes that have different clinical risk factors. This new method for identifying classes of WMSA will be important in understanding the underlying pathophysiology and in determining the impact on clinical outcomes.

Importance: Lumbar spine imaging frequently reveals findings that may seem alarming but are likely unrelated to pain. Prior work has suggested that inserting data on the prevalence of imaging findings among asymptomatic individuals into spine imaging reports may reduce unnecessary subsequent interventions., Objective: To evaluate the impact of including benchmark prevalence data in routine spinal imaging reports on subsequent spine-related health care utilization and opioid prescriptions., Design, Setting, and Participants: This stepped-wedge, pragmatic randomized clinical trial included 250 401 adult participants receiving care from 98 primary care clinics at 4 large health systems in the United States. Participants had imaging of their backs between October 2013 and September 2016 without having had spine imaging in the prior year. Data analysis was conducted from November 2018 to October 2019., Interventions: Either standard lumbar spine imaging reports (control group) or reports containing age-appropriate prevalence data for common imaging findings in individuals without back pain (intervention group)., Main Outcomes and Measures: Health care utilization was measured in spine-related relative value units (RVUs) within 365 days of index imaging. The number of subsequent opioid prescriptions written by a primary care clinician was a secondary outcome, and prespecified subgroup analyses examined results by imaging modality., Results: We enrolled 250 401 participants (of whom 238 886 [95.4%] met eligibility for this analysis, with 137 373 [57.5%] women and 105 497 [44.2%] aged >60 years) from 3278 primary care clinicians. A total of 117 455 patients (49.2%) were randomized to the control group, and 121 431 patients (50.8%) were randomized to the intervention group. There was no significant difference in cumulative spine-related RVUs comparing intervention and control conditions through 365 days. The adjusted median (interquartile range) RVU for the control group was 3.56 (2.71-5.12) compared with 3.53 (2.68-5.08) for the intervention group (difference, -0.7%; 95% CI, -2.9% to 1.5%; P = .54). Rates of subsequent RVUs did not differ between groups by specific clinical findings in the report but did differ by type of index imaging (eg, computed tomography: difference, -29.3%; 95% CI, -42.1% to -13.5%; magnetic resonance imaging: difference, -3.4%; 95% CI, -8.3% to 1.8%). We observed a small but significant decrease in the likelihood of opioid prescribing from a study clinician within 1 year of the intervention (odds ratio, 0.95; 95% CI, 0.91 to 1.00; P = .04)., Conclusions and Relevance: In this study, inserting benchmark prevalence information in lumbar spine imaging reports did not decrease subsequent spine-related RVUs but did reduce subsequent opioid prescriptions. The intervention text is simple, inexpensive, and easily implemented., Trial Registration: ClinicalTrials.gov Identifier: NCT02015455.

A movement towards integrated behavioral health (IBH) in primary care continues to grow, among an accumulating evidence base for its effectiveness for improving care. However, healthcare organizations struggle to navigate where to target their limited resources for improving integration. We evaluated a cross-model framework of IBH core processes and structures. We used a mixed-methods approach for evaluation of the framework, which included (a) an evaluation survey of national experts and stakeholders, (b) crosswalks with common IBH measures, and (c) a real-world usability test. Five core IBH principles, mapping to 25 processes, and nine clinic structures were defined. Survey responses from 29 IBH domain and policy experts and stakeholders resulted in uniformly high ratings of importance and variable levels of feasibility for measurement, particularly with respect to electronic health record (EHR) systems. A real-world usability test resulted in good uptake and use of the framework across a state-wide effort. An IBH Cross-Model Framework of core principles, processes, and structures generated good acceptability and showed good real-world utility in a state-wide effort to improve IBH across disparate levels of integration in diverse primary care settings. Findings identify feasible areas of measurement, particularly with EHR systems. Next steps include testing the relationship between the individual framework components and patient outcomes to help guide clinics towards prioritizing efforts focused on improving integration., (© Society of Behavioral Medicine 2020. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)