Evaluation of A Coaching by Telephone Intervention for Veteran and - PowerPoint PPT Presentation

VA Ann Arbor Center for Clinical Management Research Evaluation of A Coaching by Telephone Intervention for Veteran and Care Team Engagement Laura J. Damschroder, MS, MPH AcademyHealth Annual Research Meeting April 26, 2017

1 Background • Over half of all deaths can be attributable to four modifiable risk factors: tobacco use, obesity, physical inactivity and alcohol use • VHA has done well at addressing quality of care in chronic illness, but less well in addressing modifiable risk factors • Recent strategic changes in VHA have placed more emphasis on prevention including roll out of a web-based Health Risk Assessment VA Ann Arbor Center for Clinical Management Research Patel, Ann Intern Med, 2016

2 ACTIVATE Goals • To determine whether Health Risk Assessment (HRA) and Telephone Coaching improves enrollment of Veterans in structured prevention programs compared to HRA alone • To determine whether HRA and Telephone Coaching improves patient activation and cardiovascular risk compared to HRA alone VA Ann Arbor Center for Clinical Management Research

3 ACTIVATE Design: Type 1 Hybrid RCT Study Arms: HRA + telephone coach vs. HRA alone Setting: Durham and Greenville, NC; Ann Arbor MI Subject Pool: Enrolled in Primary Care Inclusion Criteria: • BMI>30 • Current Smoker • < 150 minutes of moderate/vigorous activity Exclusion Criteria: Dementia, active psychosis, impaired hearing, unable to speak English, terminal illness, no access to a phone, actively enrolled in a structured prevention program in past 6 months Contemp Clin Trials, 2017 VA Ann Arbor Center for Clinical Management Research

Theoretical Framework for Patient Change HRA Co-primary Primary Outcome Outcome Coaching HRA + Health Coaching Coaching VA Ann Arbor Center for Clinical Management Research

A Coaching by Telephone Intervention for Veterans and Care Team Engagement All participants HRA https://www.myhealth.va.gov/

Intervention participants Prevention Coach Participant Review HRA Results HLA Report Explore Preferences & Values HRA Prioritize Prevention Topics Set Prevention Goal  Enroll in Program Assess Readiness & Confidence . F/W Phone Call for EMR Note with Reinforcement Prevention Action Plan F/U Letter with Prevention Action Plan

Recruitment Letter Sent N= 3007 ACTIVATE Consort Recruitment Refused (N=813) Not Contacted (N=1216) a Enrollment Only Ineligible (N = 423) Telephone Screened Eligible (N = 555) Baseline Refused (N = 26) No Show (N = 90) a Ineligible (N=3) Consented (N = 436) Excluded prior randomization (N =19) b Randomized (N = 417) Intervention Usual Care N = 208 N =209 1 month Completed 1 month Completed (N = 172 ) (N = 192 ) 6 month Completed 6 month Completed (N = 177 ) (N = 199 ) ____________________ ____________________ Dropouts (N = 27) c Dropouts (N =9 ) c No Longer Eligible (N = 4) No Longer Eligible (N = 1) Foot Note: a- patients were unable to complete recruitment process due to phone outages, not showing for appointment, non-responders to phone calls. b – includes formal and informal withdrawal prior to randomization as well as exclusion for failure to adhere to study protocol prior to randomization. c – includes formal and informal withdrawal post randomization.

8 ACTIVATE – Baseline Cohort Baseline Characteristics Intervention Usual Care (n=208) (n=209) Actual Age, Mean (SD) 55.3 (12.7) 56.3 (11.7) HRA Health Age, Mean (SD) 60 (12.9) 60.7 (12.4) HRA Health Age minus 4.7 (5.6) 4.4 (5.9) Actual Age, Mean (SD) Male 83% 88% Race Black or African American 43% 38% White 48% 53% Married/Living as married 46% 56% Employed full/part-time 38% 35% VA Ann Arbor Center for Clinical Management Research

9 ACTIVATE Inclusion Criteria Intervention Usual Care Inclusion Criteria (n=208) (n=209) BMI>=30 77% 82% Physical Activity<150 48% 53% minutes/week Current smoker of cigarettes 42% 40% Total # of Inclusion Criteria met 42% 41% 1 2 48% 47% 3 10% 12% VA Ann Arbor Center for Clinical Management Research

Activate--Analysis • Patient Unit of Randomization and Analysis • Primary Outcome: – Enrollment in Structured Prevention Program (1 and 6 months) • Secondary Outcomes: – Patient Activation Measure: PAM-13 Score (1 and 6 months) – Framingham Risk Score (6 months) • Logistic Regression to estimate treatment difference in enrollment • General Linear Models with parameters of time and group by time interaction to estimate treatment group differences in PAM and FRS VA Ann Arbor Center for Clinical Management Research

Adherence to Telephone Coaching Intervention Participants (n=208) • 93% of participants completed Call #1 • 88% of participants completed Call #2 • 14 participants (7%) received neither call VA Ann Arbor Center for Clinical Management Research

12 ACTIVATE Results Enrolled and Participated in Prevention Program Odds Ratio (95% CI) Outcome Intervention P value vs Usual Care 0.51 0.29 2.54 Ever Enrolled <.0001 (0.43, 0.58) (0.23, 0.36) (1.66, 3.89) Ever Participated 0.40 0.23 2.28 0.0004 (0.33, 0.48) (0.17, 0.29) (1.45, 3.59) VA Ann Arbor Center for Clinical Management Research

13 ACTIVATE Results Secondary Outcomes (PAM) & (FRS) P value PAM 61.5 61.5 Baseline (60.3, 62.7) (60.3, 62.7) 63.2 61.8 1.5 One Month 0.20 (61.5, 64.9) (60.1, 63.4) (-0.8, 3.7) 66.3 63.9 2.5 Six Months 0.03 (64.6, 68.1) (62.2, 65.5) ( 0.2, 4.7) Framingham 22.3 22.3 Baseline (20.7, 24.0) (20.7, 24.0) 22.7 21.9 0.7 Six Months 0.33 (20.8, 24.5) (20.1, 23.7) (-0.7, 2.2) VA Ann Arbor Center for Clinical Management Research

14 Prevention Program Chosen by Intervention Participants Total VA Program Non VA Program Diet/Weight Loss 41% 10% 51% Exercise 3% 24% 27% Smoking Cessation 11% 9% 19% Other Program 0 3% 3% Total 55% 45% 100% VA Ann Arbor Center for Clinical Management Research

15 Prevention Program Chosen by Intervention Participants Total VA Program Non VA Program Diet/Weight Loss 41% 10% 51% Exercise 3% 24% 27% Smoking Cessation 11% 9% 19% Other Program 0 3% 3% Total 55% 45% 100% VA Ann Arbor Center for Clinical Management Research

16 Limitations • Primary Outcome was obtained by patient self report – Validation of VA’s MOVE! program enrollment • 27 of 47 patients (81%) who reported enrollment showed EMR evidence of participation • 9 of 324 patients (2%) who did not report enrollment showed EMR evidence of participation • Kappa=.78 • Prior research shows that 10% of MOVE! referrals enroll – No way to determine non-VA program participation (45% of intervention patients) VA Ann Arbor Center for Clinical Management Research Kahwati, TBM, 2011

17 Conclusions • HRA results followed by telephone coaching: – Improves patient activation – Facilitates Veterans enrollment and participation in structured prevention programs to address health behaviors and health risks …compared to HRA alone • Despite higher enrollment and participation CVD risk did not improve by 6-months VA Ann Arbor Center for Clinical Management Research

Impact and the road ahead • Impact – This study helped inform the VHA’s roll out of the HRA. • Challenges – Connectivity with primary care • Next Steps VA Ann Arbor Center for Clinical Management Research

Study Team and Partners Study Team NCP Partners Eugene Z. Oddone, M.D., M.H.Sc. Jane Kim, MD, MPH Laura J. Damschroder, MPH, MS Michael Goldstein, MD Jennifer Gierisch, PhD Peg Dundon, PhD Maren Olsen, PhD Linda Kinsinger, MD, MPH Linda Sanders, MPH Kathleen Pitman, RN, MPH Angela Fagerlin, PhD Heidi Martin Jordan Sparks, MPH Felicia McCant, MSSW Carrie Mae, MPH Marsha Turner, MPH David Currie, MPH 19

A Coaching by Telephone Intervention for Veterans and Care Team Engagement Intervention participants Prevention Coach Participant Review HRA Results HLA Report Explore Preferences & Values HRA Prioritize Prevention Topics Set Prevention Goal  Enroll in Program Assess Readiness & Confidence . F/W Phone Call for EMR Note with Reinforcement Prevention Action Plan F/U Letter with Prevention Action Plan PACT Team VA Ann Arbor Center for Clinical Management Research Activated for Prevention

21 ACTIVATE-- Baseline Measures Intervention Usual Care Baseline Common Measures Mean (SD) Mean (SD) Self Rated Health 68% 70% (Good, Very Good, Excellent) PHQ8 Total Score 6.8 (5.4) 7.4 (5.5) (Range 0-24, 0=No Depression) MOS-6 Sleep Scale Score 61.2 (21.3) 60.8 (22.2) (0-100, Higher is better) Overall pain in past week 4.4 (2.7) 4.7 (2.7) (0-10, 0= No pain) Past 30 days, how many days pain 10 (11.3) 11 (11.2) disrupted usual activities VA Ann Arbor Center for Clinical Management Research