Browsing by Author "Almirall, Daniel"

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    Identifying optimal level-of-care placement decisions for adolescent substance use treatment
    (Elsevier, 2020-07) Agniel, Denis; Almirall, Daniel; Burkhart, Q.; Grant, Sean; Hunter, Sarah B.; Pedersen, Eric R.; Ramchand, Rajeev; Griffin, Beth Ann; Social and Behavioral Sciences, School of Public Health
    Background: Adolescents respond differentially to substance use treatment based on their individual needs and goals. Providers may benefit from guidance (via decision rules) for personalizing aspects of treatment, such as level-of-care (LOC) placements, like choosing between outpatient or inpatient care. The field lacks an empirically-supported foundation to inform the development of an adaptive LOC-placement protocol. This work begins to build the evidence base for adaptive protocols by estimating them from a large observational dataset. Methods: We estimated two-stage LOC-placement protocols adapted to individual adolescent characteristics collected from the Global Appraisal of Individual Needs assessment tool (n = 10,131 adolescents). We used a modified version of Q-learning, a regression-based method for estimating personalized treatment rules over time, to estimate four protocols, each targeting a potentially distinct treatment goal: one primary outcome (a composite of ten positive treatment outcomes) and three secondary (substance frequency, substance problems, and emotional problems). We compared the adaptive protocols to non-adaptive protocols using an independent dataset. Results: Intensive outpatient was recommended for all adolescents at intake for the primary outcome, while low-risk adolescents were recommended for no further treatment at followup while higher-risk patients were recommended to inpatient. Our adaptive protocols outperformed static protocols by an average of 0.4 standard deviations (95 % confidence interval 0.2-0.6) of the primary outcome. Conclusions: Adaptive protocols provide a simple one-to-one guide between adolescents' needs and recommended treatment which can be used as decision support for clinicians making LOC-placement decisions.
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    The implementation of a translational study involving a primary care based behavioral program to improve blood pressure control: The HTN-IMPROVE study protocol (01295)
    (BMC, 2010-07-16) Bosworth, Hayden B.; Almirall, Daniel; Weiner, Bryan J.; Maciejewski, Mathew; Kaufman, Miriam A.; Powers, Benjamin J.; Oddone, Eugene Z.; Lee, Shoou-Yih D.; Damush, Teresa M.; Smith, Valerie; Olsen, Maren K.; Anderson, Daren; Roumie, Christianne L.; Rakley, Susan; Del Monte, Pamela S.; Bowen, Michael E.; Kravetz, Jeffrey D.; Jackson, George L.; Medicine, School of Medicine
    Background Despite the impact of hypertension and widely accepted target values for blood pressure (BP), interventions to improve BP control have had limited success. Objectives We describe the design of a 'translational' study that examines the implementation, impact, sustainability, and cost of an evidence-based nurse-delivered tailored behavioral self-management intervention to improve BP control as it moves from a research context to healthcare delivery. The study addresses four specific aims: assess the implementation of an evidence-based behavioral self-management intervention to improve BP levels; evaluate the clinical impact of the intervention as it is implemented; assess organizational factors associated with the sustainability of the intervention; and assess the cost of implementing and sustaining the intervention. Methods The project involves three geographically diverse VA intervention facilities and nine control sites. We first conduct an evaluation of barriers and facilitators for implementing the intervention at intervention sites. We examine the impact of the intervention by comparing 12-month pre/post changes in BP control between patients in intervention sites versus patients in the matched control sites. Next, we examine the sustainability of the intervention and organizational factors facilitating or hindering the sustained implementation. Finally, we examine the costs of intervention implementation. Key outcomes are acceptability and costs of the program, as well as changes in BP. Outcomes will be assessed using mixed methods (e.g., qualitative analyses--pattern matching; quantitative methods--linear mixed models). Discussion The study results will provide information about the challenges and costs to implement and sustain the intervention, and what clinical impact can be expected.