Address Treatment Barriers Research Articles

Expert Opinion on Optimising Type2 Diabetes Treatment Using Fixed-Ratio Combination of Basal Insulin and GLP-1RA for Treatment Intensification and Simplification.

The management of type2 diabetes (T2D) often necessitates treatment intensification, and sometimes simplification to achieve glycaemic targets and mitigate complications. This expert opinion paper evaluates the use and positioning of the fixed-ratio combinations (FRCs) of basal insulin (BI) and glucagon-like peptide1 receptor agonists (GLP-1RAs) in optimising T2D management. On the basis of the evidence presented and discussions, these FRCs offer a promising approach for both treatment intensification and simplification in people with suboptimal glucose control despite receiving various therapies. In treatment intensification, FRCs provide a synergistic effect by addressing multiple pathophysiological defects contributing to hyperglycaemia. These FRCs effectively control both fasting and postprandial glucose (PPG) excursions, offering significantly improved glycaemic control with a lower hypoglycaemia risk and weight neutrality compared to traditional or complex insulin regimens. Moreover, the reduced injection frequency (once daily) and flexibility in the dosing schedule (with any major meal of the day) help mitigate patient resistance to insulin initiation or titration. This further reduces treatment burden, facilitating treatment adherence and enhancing patient convenience. These key benefits of FRCs over complex insulin regimens play a crucial role in long-term glycaemic management and overall treatment outcomes. Hence, the timely use of FRCs in the treatment algorithm for people with T2D represents a valuable strategy for optimising glycaemic control, addressing treatment barriers and enhancing patient-reported outcomes.

Adherence Rates and Barriers to Second-Generation Antipsychotic Medication Use in Youth with Bipolar Spectrum Disorders Who Have Overweight/Obesity.

Objective: Youth with bipolar spectrum disorders (BSD) are frequently prescribed second-generation antipsychotics (SGAs). Nonadherence to treatment often results in increased mood symptoms and diminished quality of life. We examined SGA adherence rates and adherence barriers among youth who have overweight/obesity and are diagnosed with BSD enrolled in a multisite pragmatic clinical trial. Methods: SGA adherence and adherence barriers at baseline via patient- and caregiver report was assessed. Adherence was defined as taking ≥70% of prescribed SGA doses in the past week. The weighted Kappa statistic was used to measure child-caregiver agreement about adherence rates, barriers, and caregiver assistance. Regression analyses were used to examine associations of caregiver assistance, age, sex, race, insurance status, dosing frequency, and number of concomitant medications with adherence. Barriers to adherence were analyzed separately for youth and their caregivers, using logistic regression to assess associations between informant-reported barriers and informant-reported adherence. Results: Participants included 1485 patients and/or caregivers. At baseline, 88.6% of patients self-reported as adherent; 92.0% of caregivers reported their child was adherent. Concordance between patients and caregivers was moderate (k = 0.42). Approximately, 50% of the sample reported no adherence barriers. Frequently endorsed barriers included forgetting, side effects, being embarrassed to take medications, and preferring to do something else. Concordance between informants regarding adherence barriers was weak (k = 0.05-0.36). Patients and caregivers who did not endorse adherence barriers reported higher adherence than those who endorsed barriers. Male sex and having once daily dosing of medications were associated with lower adherence. Discussion: One-week patient- and caregiver-reported adherence was high in this sample. Half of the sample reported adherence barriers. Most commonly endorsed barriers were forgetting, side effects, being embarrassed, and preferring to do something else. Caregivers and patients have unique perspectives regarding adherence barriers. Understanding and addressing treatment barriers in clinical practice may facilitate adherence.

Healthcare professionals' perceptions and management of obesity & knowledge of glucagon, GLP-1, GIP receptor agonists, and dual agonists.

Anti-obesity medications (AOMs) have historically had limited weight-loss efficacy. However, newer glucagon-like peptide-1 receptor agonist (GLP-1 RA)-based therapies seem to be more effective, including dual agonists of GLP-1R and the glucagon receptor (GCGR) or glucose-dependent insulinotropic polypeptide receptor. To explore healthcare professionals' (HCPs) experience in obesity treatment and their understanding of agonists of GCGR, glucose-dependent insulinotropic polypeptide (GIP) RA, and GLP-1 RA. This cross-sectional online survey of HCPs prescribing AOMs was conducted in the United States in 2023 with a questionnaire designed to evaluate prescribing behavior and understanding of GCGR, GIP RA, and GLP-1 RA. The 785 respondents (251 primary-care physicians [PCPs], 263 endocrinologists, and 271 advanced practice providers [APPs]) reported 55% of their patients had obesity (body mass index ≥30kg/m2 or ≥27 with weight-related complications) and recommended AOMs to 49% overall, significantly more endocrinologists (57% of patients, p<0.0005) than PCPs (43%) or APPs (46%). The greatest barriers to treatment were medication cost/lack of insurance (mean 4.2 on 1-5 scale [no barrier-extreme barrier]), low patient engagement/adherence (3.3), and inadequate time/staff (3.1). Metformin was the type 2 diabetes (T2D) medication most commonly prescribed to treat obesity in T2D patients (92.5% of respondents). Most HCPs (65%) were very/extremely familiar with GLP-1 RA, but only 30% with GIP RA and 16% with GCGR. Most HCPs expected dual GCGR/GLP-1 RA to benefit many obesity-related conditions; however, only a minority of HCPs perceived that they would benefit non-cardiometabolic complications of obesity. Among HCPs prescribing AOMs, gaps exist in the management of people living with obesity as <50% are prescribed AOMs. Barriers to treatment indicate a need to improve access to AOMs. HCPs were less familiar with GCGR or GIP RA than GLP-1 RA but expect dual GCGR/GLP-1 RA may offer additional benefits, potentially addressing treatment barriers and access. Thus, there is a need for greater education among HCPs regarding the mechanism of action and therapeutic effects of GCGR agonists, and dual GCGR/GLP-1 RA, so that the full range of obesity-related complications can be effectively treated.

SARS-CoV-2 Antiviral Prescribing Gaps Among Nonhospitalized High-Risk Adults.

Within a multistate clinical cohort, SARS-CoV-2 antiviral prescribing patterns were evaluated from April 2022-June 2023 among nonhospitalized patients with SARS-CoV-2 with risk factors for severe COVID-19. Among 3247 adults, only 31.9% were prescribed an antiviral agent (87.6% nirmatrelvir/ritonavir, 11.9% molnupiravir, 0.5% remdesivir), highlighting the need to identify and address treatment barriers.

Addressing Attrition from Psychotherapy for PTSD in the U.S. Department of Veterans Affairs

The United States Department of Veterans Affairs (VA) uses a systematized approach for disseminating evidence-based, trauma-focused psychotherapies for post-traumatic stress disorder (PTSD). Within this approach, veterans with PTSD must often choose between Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT), each delivered in their standard protocols. Many veterans have been greatly helped by this approach. Yet limiting trauma-focused therapy to these two options leaves the VA unable to fully address the needs of a variety of veterans. This limitation, among other factors, contributes to the suboptimal attrition rates within the VA. The present review proposes solutions to address treatment barriers that are both practical (such as time and travel constraints) and psychological (such as resistance to trauma exposure). By reducing barriers, attrition may lessen. Proposed countermeasures against practical barriers include intensive protocols, shortened sessions, telehealth, smartphone application delivery, or any combination of these methods. Countermeasures against psychological barriers include alternative evidence-based treatment programs (such as Acceptance and Commitment Therapy), intensive protocols for exposure-based treatments, and the integration of components from complementary treatments to facilitate PE and CPT (such as Motivational Interviewing or family therapy). By further tailoring treatment to veterans’ diverse needs, these additions may reduce attrition in VA services for PTSD.

Development and usability testing of a chatbot to promote mental health services use among individuals with eating disorders following screening.

A significant gap exists between those who need and those who receive care for eating disorders (EDs). Novel solutions are needed to encourage service use and address treatment barriers. This study developed and evaluated the usability of a chatbot designed for pairing with online ED screening. The tool aimed to promote mental health service utilization by improving motivation for treatment and self-efficacy among individuals with EDs. A chatbot prototype, Alex, was designed using decision trees and theoretically-informed components: psychoeducation, motivational interviewing, personalized recommendations, and repeated administration. Usability testing was conducted over four iterative cycles, with user feedback informing refinements to the next iteration. Post-testing, participants (N= 21) completed the System Usability Scale (SUS), the Usefulness, Satisfaction, and Ease of Use Questionnaire (USE), and a semi-structured interview. Interview feedback detailed chatbot aspects participants enjoyed and aspects necessitating improvement. Feedback converged on four themes: user experience, chatbot qualities, chatbot content, and ease of use. Following refinements, users described Alex as humanlike, supportive, and encouraging. Content was perceived as novel and personally relevant. USE scores across domains were generally above average (~5 out of 7), and SUS scores indicated "good" to "excellent" usability across cycles, with the final iteration receiving the highest average score. Overall, participants generally reflected positively on interactions with Alex, including the initial version. Refinements between cycles further improved user experiences. This study provides preliminary evidence of the feasibility and acceptance of a chatbot designed to promote motivation for and use of services among individuals with EDs. Low rates of service utilization and treatment have been observed among individuals following online eating disorder screening. Tools are needed, including scalable, digital options, that can be easily paired with screening, to improve motivation for addressing eating disorders and promote service utilization.

0767 Clinical implementation of a program to improve PAP acceptance and adherence for sleep disordered breathing among Veterans: Preliminary results

Abstract Introduction Positive airway pressure (PAP) is the gold standard in treating sleep disordered breathing (SDB); however, consistent use of this therapy has challenges such as comfort and equipment optimization. Despite various educational, technological, psychosocial and pharmacological strategies, the average adherence rate of 34% have changed very little over the past 20 years. A recent study of 3013 US veterans determined a baseline average PAP adherence rate of 50%. We developed and implemented a novel PAP readiness education program (PREP) for veterans newly diagnosed with SDB in a Veterans Administration sleep clinic to promote greater PAP acceptance and adherence. Methods Patients (N=63, Mean age 62.2±12.4 years) with newly diagnosed SDB were offered a 1-hour telehealth session prior to initiating PAP therapy that included psychoeducation about SDB and PAP treatment expectations, with troubleshooting techniques (i.e. scheduled practice, mindfulness). A 1-week follow-up call was conducted to communicate PAP data and address treatment barriers. PAP use reports were downloaded and analyzed at 1-7 days (first week), 1-30 days (first month), and 31-60 days (60-days) post-PAP initiation. PAP acceptance was defined as ≥1 day of use and adherence as ≥4 hours of use at each timepoint. Results Among 63 Veterans offered PREP, 66.6% (n=42) participated in PREP. Among participants, acceptance of PAP was as follows: 57.1% used ≥1 day in the first week, 64.3% used ≥1 day in the first month, and 45.2% used ≥1 day at 60-days post-PAP initiation. Percent of days with use ≥4 hours was 28.9% ±30.4 in the first week and 24.9% ±30.0 in the first month. PAP adherence at 60-days post-PAP initiation was 34.3% ±38.5 at 60-days. Conclusion Implementation of a 1-session plus 1-week follow-up call PAP readiness education program within a sleep medicine clinic was well received by patients and resulted in PAP acceptance by 2/3 of veterans in the first month post-PAP initiation. PAP adherence results may have reflected the impact of a nationwide PAP device recall that occurred during the study period. Further work is needed to test this intervention in a clinical population and to identify predictors of PAP acceptance and adherence in real-world clinical settings. Support (If Any) AASM Foundation #211-FP-19, VAGLAHS GRECC and CSHIIP

Co-occurring OCD and Panic Disorder: A Review of Their Etiology and Treatment.

Estimated rates of co-occurrence between obsessive and compulsive disorder (OCD) and panic disorder (PD) are notable, but vary considerably, with rates from epidemiological and clinical studies ranging from 1.8% to 22% (Rector et al., 2017). We reviewed the current empirical literature on the etiology, treatment, diagnostic assessment, and differential diagnosis of co-occurring OCD/PD. Best practices for cognitive-behavioral treatment, including identifying and addressing treatment barriers are also addressed. Although it is acknowledged in current literature that co-occurring OCD and PD levels may be clinically significant, there remains a need to thoroughly examine the possible consequences and future research directions of this overlap. Future research must continue to elucidate the biological and environmental causes of OCD/PD co-occurrence.

Primary Care Treatment Integrating Motivation and Exposure for PTSD Symptoms and Hazardous Alcohol Use: A Case Series

Symptoms of posttraumatic stress disorder (PTSD) and hazardous alcohol use are highly comorbid. Research on integrated interventions to address PTSD symptoms and hazardous alcohol use concurrently has demonstrated efficacy, yet integrated treatments are underutilized. Both patient (e.g., stigma, scheduling/logistics) and clinician (e.g., concern about symptom exacerbation and/or treatment dropout) barriers may impede utilization of integrated interventions among those with comorbid PTSD symptoms and hazardous alcohol use. Primary care behavioral health models (PCBH), in which embedded behavioral health providers deliver treatment to individuals with mild or moderate behavioral health symptoms in primary care, may help address treatment barriers by offering accessible behavioral health interventions in a destigmatizing setting. This paper presents two case examples from a randomized controlled trial testing the efficacy of an integrated intervention for PTSD symptoms and hazardous alcohol use developed for and delivered in primary care. Outcome data and session-by-session content for two participants are included, along with discussion of barriers encountered during the course of treatment. Clinician-suggested strategies for navigating barriers to facilitate utilization of integrated interventions for PTSD symptoms and hazardous alcohol use are also discussed.

Community coalition and key stakeholder perceptions of the community opioid epidemic before an intensive community-level intervention

IntroductionOpioid overdoses are a major public health emergency in the United States. Despite effective treatments that can save lives, access to and utilization of such treatments are limited. Community context plays an important role in addressing treatment barriers and increasing access. The HEALing Communities Study (HCS) is a multisite community-level cluster-randomized trial that will study implementation and outcomes of a community coalition-based intervention (Communities that HEAL [CTH]) that implements evidence-based practices (EBPs) to reduce opioid overdose deaths in four states. To examine contextual factors critical to understanding implementation, we assessed the perspectives of community members about their communities, current substance use–related services, and other important issues that could impact intervention implementation. MethodsResearchers conducted 382 semi-structured qualitative interviews in the HCS communities. Interviews were audio-recorded and transcribed; researchers subsequently analyzed data using directed content analysis based on the constructs of the RE-AIM/PRISM implementation science framework to identify key themes within the external community context. ResultsDespite the diversity in states and communities, four similar themes related to the external community context emerged across communities: These themes included the importance of understanding: 1) community risk perceptions, 2) levels of stigma, 3) the health services environment and the availability of substance use services, and 4) funding for substance use services. ConclusionUnderstanding and addressing the external community context in which the CTH intervention and EBPs are implemented are crucial for successful health services-related and community engaged interventions. While implementing EBPs is a challenging undertaking, doing so will help us to understand if and how a community-based intervention can successfully reduce opioid overdose deaths and influence both community beliefs and the community treatment landscape.

Patient and Provider Perspectives on Glaucoma Treatment Adherence: A Delphi Study in Urban Alabama.

Patients with glaucoma and providers recognized perceived treatment efficacy, patient-provider relationship, psychological stress, instillation skill, good quality of life, and forgetfulness as key determinants of glaucoma adherence. This shared insight could help shape the development of clinical and behavioral interventions for addressing treatment barriers and improving adherence. Despite their impact on adherence in glaucoma, sociobehavioral factors may not be adequately explored during clinical consultations. We aimed to elicit consensus between patients and providers around key determinants of adherence and hypothesized that patients would place greater emphasis on sociobehavioral factors compared with providers. A two-round Delphi survey was used to assess treatment beliefs, barriers, facilitators, motivators, and needs among 18 patients with glaucoma and providers. In round 1, agreement with 46 statements was scored on a 5-point Likert scale (strongly disagree to strongly agree). Statements with which 80% or more of panelists agreed reached consensus and advanced to round 2, where participants were asked to prioritize them based on their importance to treatment. There was consensus regarding the influence of perceived treatment efficacy, good provider relationship, good quality of life, psychological stress, glaucoma knowledge, instillation skill, and forgetfulness on glaucoma adherence. For statements that failed to reach consensus, the Bonferroni-corrected Mann-Whitney U test revealed that the greatest differences between patients and providers pertained to regimen complexity (provider median, 4 [interquartile range {IQR}, 1]; patient median, 1.5 [IQR, 1]; P = .002), instillation skill (providers, 4 [IQR, 0.5]; patients, 2 [IQR, 1]; P = .001), and low motivation (providers, 3 [IQR, 2.25]; patients, 1 [IQR, 0]; P = .003). Although patients and providers prioritized sociobehavioral factors as key determinants of adherence, disagreement between these groups was observed in other areas. Continued juxtaposition of patient and provider perspectives could spotlight underexplored areas and guide the development of successful interventions for improving adherence.

‘If not for this support, I would have left the treatment!': Qualitative study exploring the role of social support on medication adherence among pulmonary tuberculosis patients in Western India

ABSTRACT Social support has been identified as a significant factor in addressing treatment barriers and facilitating treatment adherence. Using a descriptive design, this qualitative study aims at sharing personal feelings and social support-related experiences among pulmonary tuberculosis (TB) patients in Western India. A semi-structured interview guide was designed, and thirty-seven in-depth interviews were conducted. Descriptive thematic analysis was employed for reporting the themes and the results. The participants highlighted diverse social support experiences like empathy, compassion, trust, neglect, tangible aid, strained relationships with in-laws, health provider’s support, strength, and motivation which influences their treatment adherent behaviour. Contrasting differences of social support experiences among adherent and non-adherent TB patients were also reported. The study has important ramifications for developing patient-centric social support intervention strategies, TB policy, and practice. The study has shown, ‘if not for this support’, patients would have left the treatment, and it is mainly because this debilitating disease robs people of their physical, social, economic, psychological, and emotional well-being far beyond the period when treatment is being administered. However, we resonate that addressing social support is not the only way, and TB elimination overall will require an optimal mix of enhanced biomedical, social, economic, and policy interventions.

Changes in community knowledge and attitudes related to female genital fistula following the implementation of a multi-component intervention in Nigeria and Uganda

Background Despite well-documented individual-level barriers to fistula care access including limited awareness, psychosocial deterrents, and contextual factors, less is known about how these factors manifest and operate at community level. Social normative community perspectives – their knowledge, attitudes and actions in relation to women living with fistula – can offer insight into this mechanism. Our study describes changes in fistula knowledge and attitudes toward those living with fistula among community members in Nigeria and Uganda following implementation of a multi-component intervention addressing treatment barriers. Methods This study adopts a pre-post qualitative design with a comparison site and draws on focus group discussions with female and male community members from three sites in Nigeria and Uganda. Transcripts were analyzed for passages presenting community knowledge and attitudes related to fistula and perceptions of women living with fistula. Summary memos were developed and used to compare viewpoints across study sites and time points and between men and women. Results Community members demonstrated basic knowledge of symptoms of fistula and mixed understanding of its causes; prolonged obstructed labor and iatrogenic causes were most known. Myths and misconceptions around fistula causes commonly relate to incorrect biomedical understanding, witchcraft, and promiscuity. To varying degrees, fistula cause knowledge increased, and misinformation decreased among endline intervention groups with less observed change in endline comparison groups. Awareness that fistula can be surgically repaired free of charge at fistula centers varied across study regions, with higher awareness among individuals who personally knew someone who experienced repair at a center. Although community members at baseline and endline perceive shame and stigma as affecting women living with fistula, community attitudes toward these women show an increase in empathy at endline in intervention areas. Conclusions Community empathy and willingness to help women living with fistula, coupled with reduction in misinformation regarding fistula, its cause and how to access treatment, is an incremental outcome associated with the implementation of a multi-component intervention to address treatment barriers. However, findings reveal that social and behavioral change happens slowly and that further programmatic research on society-targeted approaches emphasizing comprehensive community understanding of fistula and stigma reduction is needed.

Are Barriers to Psychotherapy Treatment Seeking Indicators of Social Determinants of Health?: A Critical Review of the Literature

One of the most persistent and troubling health disparities is the underutilization of mental health services by individuals with marginalized aspects of their identity. We provide a critical review of the literature of barriers to psychotherapy initiation and the connection to social determinants of health. We propose a change from a deficit-based view of the problem to a strength-based view that include the following strategies: family therapy treatments designed to reduce barriers, telehealth as an option to address treatment barriers, changes to the recruitment of therapists-in-training, and person of the therapist development.

Psychosocial Outcomes of Australian Male and Female Veterans Following Participation in Peer-Led Adventure-Based Therapy

Adjunct or second-line therapies are increasingly being utilised among military populations to address treatment barriers and improve mental health outcomes. This study evaluated the psychosocial outcomes of an Australian peer-led adventure-based therapy program, Trojan’s Trek, for 60 ex-service military personnel (i.e., veterans, 56.7% male). Participants completed 1 of 6 Queensland Trojan’s Trek programs—a 6-day, live-in program consisting of 10–12 structured CBT-based group sessions and 11 nature-based activities—between March 2018 and March 2019. A non-controlled, within-subjects longitudinal design was utilised with assessment at pre-intervention, post-intervention, and 2-month follow-up. Changes in psychosocial outcomes were assessed using the Depression, Anxiety, and Stress Scale 21 (DASS-21), PTSD Checklist-5 (PCL-5), Positive and Negative Interactions Scale (PNI), General Self-Efficacy Scale (GSES), and the Life Satisfaction Questionnaire (LSQ). Mixed-factorial ANOVAs indicated a significant time x gender effect for anxiety (male <em>F</em>[2, 28] = 31.1, <em>p</em> &lt; .001; female <em>F</em>[2, 19] = 4.05, <em>p</em> = .025); and stress (male <em>F</em>[2, 28] = 45.3, <em>p</em> &lt; .001; female <em>F</em>[2, 19] = 9.98, <em>p</em> &lt; .001). There were significant improvements between pre- and post-intervention for depression, anxiety (male only), stress, posttraumatic stress, perceived positive relationships with friends and family, perceived negative relationships with family and partners, self-efficacy, and life satisfaction. Improvements were maintained or established at 2-month follow-up for depression, anxiety (male and female), stress, posttraumatic stress, perceived negative relationships with friends, and self-efficacy. This study demonstrates utility of the Trojan’s Trek program for male and female Australian veterans with mental health difficulties. However, a controlled trial is required to determine program efficacy.

Understanding why at-risk population segments do not seek care for tuberculosis: a precision public health approach in South India

IntroductionDelaying care-seeking for tuberculosis (TB) symptoms is a major contributor to mortality, leading to worse outcomes and spread. To reduce delays, it is essential to identify barriers to care-seeking and...

Improving management of the genitourinary syndrome of menopause: evaluation of a health system–based, cluster-randomized intervention

Genitourinary symptoms are common in postmenopausal women and adversely affect the quality of life. National surveys and data collected from our healthcare system indicate that postmenopausal women with the genitourinary syndrome of menopause often fail to receive appropriate diagnosis or treatment. To promote greater detection and treatment of the genitourinary syndrome of menopause, we created and tested a clinician-focused health system intervention that included clinician education sessions and a suite of evidence-based electronic health record tools. Using a cluster-randomized design, we allocated primary care (16) and gynecology (6) clinics to the intervention or control group. From September to November 2014, we provided training about the diagnosis and treatment of genitourinary syndrome of menopause in face-to-face presentations at each intervention clinic and in an online video. We developed clinical decision support tools in the electronic health record that contained an evidence-based, point-of-care knowledge resource, a standardized order set, and a checklist of patient education materials for the patient's after visit summary. The tools aimed to facilitate accurate diagnostic coding and prescribing (SmartSet, SmartRx) along with relevant patient information (SmartText). Clinicians who only performed visits at control clinics received no training or notification about the tools. Our primary outcome was vulvovaginal diagnoses made at well visits for women at the age of 55 years and older from November 15, 2014 to November 15, 2015. We also assessed urinary diagnoses, vaginal estrogen prescriptions, and use of the electronic tools. There was departmental support for the intervention but no prioritization within the healthcare system to incentivize change. In the 1-year period, 386 clinicians performed 14,921 well visits for women at the age of 55 years and older. Among the 190 clinicians who performed well visits in the intervention clinics, 109 (57.4%) completed either in-person or online educational training. The proportion of visits that included a vulvovaginal (7.2% vs 5.8%; odds ratio, 1.27; 95% confidence interval, 0.65-2.51) or urinary diagnosis (2.5% vs 3.1%; odds ratio, 0.79; 95% confidence interval, 0.55-1.13) or vaginal estrogen prescription (4.5% vs 3.7%; odds ratio, 1.24; 95% confidence interval, 0.63-2.46) did not differ between study arms. There was a significant interaction for primary care and gynecology, which revealed more vulvovaginal diagnoses by gynecology but not primary care intervention clinics (odds ratio, 1.63; 95% confidence interval, 1.15-2.31), but there was no significant interaction for prescriptions. Clinicians in the intervention clinics were more likely to use decision support tools than those in control clinics-SmartSet (22.2% vs 1.5%; odds ratio, 18.8; 95% confidence interval, 5.5-63.8) and SmartText for patient information (38.0% vs 24.4%; odds ratio, 1.91; 95% confidence interval, 1.10-3.34). A per-protocol analysis revealed similar findings. Overall, the intervention did not lead to more diagnoses or prescription therapy for postmenopausal genitourinary symptoms but did result in greater distribution of patient information. Gynecology clinicians were more likely to address genitourinary symptoms generally and were more likely to make a vulvovaginal diagnosis after the intervention. Further efforts for improving care should consider ongoing clinician education beginning with enhanced menopause curricula in residency training. Additional interventions to consider include greater access for postmenopausal women to gynecologic care, addressing treatment barriers, and development of national performance metrics.

Reboot Online: A Randomized Controlled Trial Comparing an Online Multidisciplinary Pain Management Program with Usual Care for Chronic Pain.

Chronic pain is a prevalent and burdensome condition. Reboot Online was developed to address treatment barriers traditionally associated with accessing face-to-face chronic pain management programs. It is a comprehensive multidisciplinary online treatment program, based on an existing and effective face-to-face multidisciplinary pain program (the Reboot program). A CONSORT-compliant randomized controlled trial was conducted, enrolling adults who had experienced pain for three months or longer. Participants were randomly allocated to either an eight-lesson multidisciplinary pain management program, Reboot Online (N = 41), or to a usual care (UC) control group (N = 39). Clinical oversight was provided by a multidisciplinary team remotely, including physiotherapists and clinical psychologists. Participants were measured at baseline, post-treatment (week 16), and three-month follow-up (week 28). Intention-to-treat analyses revealed that Reboot Online was significantly more effective than UC at increasing pain self-efficacy (g = 0.69) at post-treatment, and these gains were maintained at follow-up. Similarly, Reboot Online was significantly more effective than UC on several secondary measures at post-treatment and follow-up, including movement-based fear avoidance and pain-related disability, but it did not significantly reduce pain interference or depression compared with UC. Clinician input was minimal, and adherence to Reboot Online was moderate, with 61% of participants (N = 25) completing all eight lessons. Reboot Online presents a novel approach to multidisciplinary pain management and offers an accessible, efficacious alternative and viable treatment option for chronic pain management.

Continued attendance for paediatric weight management: A multicentre, qualitative study of parents' reasons and facilitators.

Although prolonged engagement in paediatric weight management (PWM) is associated with positive treatment outcomes, little is currently known about enablers of long-term programme attendance. The purpose of our study was to explore families' reasons for and facilitators of their continued attendance at health services for PWM. Semi-structured, individual interviews were conducted with parents of children (10-17 year old; body mass index ≥85th percentile) who completed the active phase of treatment in one of four Canadian multidisciplinary clinics for PWM. Interview data were recorded digitally, transcribed verbatim and analysed thematically. Parents' (n = 40) reasons for continued clinic attendance included ongoing concerns (eg, parental concern about their child's health), actual and expected benefits from treatment (eg, lifestyle improvements) and perceived quality of care (eg, structured, comprehensive, tailored health services). Several logistical and motivational factors contributed to continued attendance, including flexible work schedules, flexible appointment times, financial resources and children's motivation for treatment. Helping families address treatment barriers and ensuring that weight management services meet families' treatment expectations are promising strategies to enhance retention in PWM to optimize health outcomes.

Addressing Challenges in Chronic Lymphocytic Leukemia with Continuing Education: Impact on Practice Behaviors and Knowledge

Background: As the era of personalized medicine draws ever closer for patients with CLL, advances in understanding of prognostic factors, biomarkers, drug classes and new agents pose a continuing challenge for clinicians to remain informed and competent in managing CLL. Clinicians must be able to determine the best treatment regimens for their patients based on cytogenetic profiles and in accordance with current treatment guidelines, evaluate recent efficacy and safety data and how they apply in practice for individual patients, anticipate and manage adverse effects, and address barriers to adherence. To address these challenges, we created continuing medical education (CME) activities focused on: 1) determination of optimal treatment strategy through use of prognostic and patient criteria, including mutations and abnormalities; 2) stratification of regimens, 3) assessment of emerging agents, sequential and combination regimens, and use of clinical trial data pertaining to patients with relapsed/refractory CLL; 4) planning individualized treatment algorithms; and, 5) addressing treatment barriers. Learner responses were evaluated to assess the influence of education.Methods: Two sets of consecutive online video-based programs were developed in January 2016 and January 2018 to address the identified knowledge and practice needs. Each respective program consisted of two 1-hour CME activities (4 hours overall) with slides, polling and live questions; programs were initially live and immediately made available on-demand at www.OMedLive.com for 6 months. CME test questions were administered at 3 time points (pre-activity, immediate post-activity, and 8-weeks post). Data from these questions, live polling responses, and learner-submitted questions during live Q&A were analyzed to determine engagement, lessons learned and continuing education gaps. Tests of statistical significance were conducted using the McNemar test for matched pairs (learners who completed both pre/post & pre/follow-up post, respectively). Effect size was computed using Cohen's d.Results: In total, 869 learners took part in the 2016 and 2018 programs (561 and 308). Overall, 103 out of 437 learners (25% at the point of evaluation) completed all pre, post, and follow-up surveys. 71% reported the educational activity positively influenced patient experience or outcome, and 76% reported it played a role in positively altering their clinical practice. As the result of education, learners reported commitments to change regarding: medical/practice knowledge (88%), care attitudes (84%), practice behavior (84%) and patient clinical outcomes (79%). Learners showed improvements on 8 knowledge questions and 4 competence questions, including statistically significant lifts in 3 case questions and 2 knowledge questions. Specifically, they demonstrated significantly improved competence via 3 case scenarios which required identifying the optimal next step for various patients with del17p, with and without IgHV unmutated CLL. They also showed significantly improved knowledge on patient-specific criteria for selecting treatment strategies for patients with CLL, and clinical staging of CLL. Although this study is limited by lack of access to practice data, outcomes results and participant questions indicate clinicians benefit from online continuing education on CLL.Conclusions: Ongoing education on CLL can yield immediate and sustained gains in knowledge, competence, and performance, and improve the ability to provide individualized treatment for patients. DisclosuresVose:Kite Pharma: Research Funding; Legend Pharmaceuticals: Honoraria; Merck Sharp & Dohme Corp.: Research Funding; Novartis: Honoraria, Research Funding; Bristol Myers Squibb: Research Funding; Celgene: Research Funding; Abbvie: Honoraria; Seattle Genetics, Inc.: Research Funding; Incyte Corp.: Research Funding; Acerta Pharma: Research Funding; Epizyme: Honoraria; Roche: Honoraria. O'Brien:Acerta: Research Funding; Gilead: Consultancy, Research Funding; Kite Pharma: Research Funding; Abbvie: Consultancy; Aptose Biosciences Inc.: Consultancy; TG Therapeutics: Consultancy, Research Funding; Regeneron: Research Funding; Sunesis: Consultancy, Research Funding; Astellas: Consultancy; Vaniam Group LLC: Consultancy; GlaxoSmithKline: Consultancy; Janssen: Consultancy; Pharmacyclics: Consultancy, Research Funding; Alexion: Consultancy; Pfizer: Consultancy, Research Funding; Celgene: Consultancy; Amgen: Consultancy.