Browsing by Author "Boustani, Malaz"
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Item Addressing Mental Health Needs of Health Care Workers through Peer Support Groups During the COVID-19 Crisis(Indiana University, 2020-12) Thornsberry, Tanner; Nault Connors, Jill; Welch, Julie; Hayden, Julie; Hartwell, Jennifer; Ober, Michael; Sotto-Santiago, Sylk; Draucker, Claire; Wasmuth, Sally; Boustani, Malaz; Overley, Ashley; Monahan, Patrick; Kroenke, KurtItem Agile implementation of alcohol screening in primary care(Springer Nature, 2024-07-11) Summanwar, Diana; Ropert, Chelan; Barton, James; Hiday, Rachael; Bishop, Dawn; Boustani, Malaz; Willis, Deanna; Medicine, School of MedicineBackground: Despite the United States Preventive Services Task Force recommendation to screen adults for unhealthy alcohol use, the implementation of alcohol screening in primary care remains suboptimal. Methods: A pre and post-implementation study design that used Agile implementation process to increase screening for unhealthy alcohol use in adult patients from October 2021 to June 2022 at a large primary care clinic serving minority and underprivileged adults in Indianapolis. Results: In comparison to a baseline screening rate of 0%, the agile implementation process increased and sustained screening rates above 80% for alcohol use using the Alcohol Use Disorders Identification Test - Consumption tool (AUDIT-C). Conclusions: Using the agile implementation process, we were able to successfully implement evidence-based recommendations to screen for unhealthy alcohol use in primary care.Item Alliances to disseminate addiction prevention and treatment (ADAPT): A statewide learning health system to reduce substance use among justice-involved youth in rural communities(Elsevier, 2021) Aalsma, Matthew C.; Aarons, Gregory A.; Adams, Zachary W.; Alton, Madison D.; Boustani, Malaz; Dir, Allyson L.; Embi, Peter J.; Grannis, Shaun; Hulvershorn, Leslie A.; Huntsinger, Douglas; Lewis, Cara C.; Monahan, Patrick; Saldana, Lisa; Schwartz, Katherine; Simon, Kosali I.; Terry, Nicolas; Wiehe, Sarah E.; Zapolski, Tamika C. B.; Pediatrics, School of MedicineBackground: Youth in the justice system (YJS) are more likely than youth who have never been arrested to have mental health and substance use problems. However, a low percentage of YJS receive SUD services during their justice system involvement. The SUD care cascade can identify potential missed opportunities for treatment for YJS. Steps along the continuum of the cascade include identification of treatment need, referral to services, and treatment engagement. To address gaps in care for YJS, we will (1) implement a learning health system (LHS) to develop, or improve upon, alliances between juvenile justice (JJ) agencies and community mental health centers (CMHC) and (2) present local cascade data during continuous quality improvement cycles within the LHS alliances. Methods/design: ADAPT is a hybrid Type II effectiveness implementation trial. We will collaborate with JJ and CMHCs in eight Indiana counties. Application of the EPIS (exploration, preparation, implementation, and sustainment) framework will guide the implementation of the LHS alliances. The study team will review local cascade data quarterly with the alliances to identify gaps along the continuum. The study will collect self-report survey measures longitudinally at each site regarding readiness for change, implementation climate, organizational leadership, and program sustainability. The study will use the Stages of Implementation Completion (SIC) tool to assess the process of implementation across interventions. Additionally, the study team will conduct focus groups and qualitative interviews with JJ and CMHC personnel across the intervention period to assess for impact. Discussion: Findings have the potential to increase SUD need identification, referral to services, and treatment for YJS.Item Anticholinergic Exposure During Rehabilitation: Cognitive and Physical Function Outcomes in Patients with Delirium Superimposed on Dementia(Elsevier, 2015-12) Kolanowski, Ann; Mogle, Jacqueline; Fick, Donna M.; Campbell, Noll; Hill, Nikki; Mulhall, Paula; Behrens, Liza; Colancecco, Elise; Boustani, Malaz; Clare, Linda; Department of Medicine, IU School of MedicineOBJECTIVES: We examined the association between anticholinergic medication exposure and subsequent cognitive and physical function in patients with delirium superimposed on dementia during rehabilitation. We also examined length of stay and discharge disposition by anticholinergic medication exposure. DESIGN: In this secondary analysis we used control group data from an ongoing randomized clinical trial. SETTING/PARTICIPANTS: Participants with delirium and dementia were enrolled at admission to post-acute care. These 99 participants had a mean age of 86.11 (±6.83) years; 67.6% were women; 98% were Caucasian; and 33% were positive for at least one APOE e4 allele. MEASURES: We obtained daily measures of cognitive and physical function using: Digit Span; memory, orientation and attention items from the Montreal Cognitive Assessment; CLOX; the Confusion Assessment Method; and the Barthel Index. Anticholinergic medication exposure was measured weekly using the Anticholinergic Cognitive Burden Scale. RESULTS: Using multilevel models for time we found that greater use of clinically relevant anticholinergic medications in the previous week reduced cognitive and physical function, as measured by Digit Span Backwards and the Barthel index, in the current week. There was no effect of anticholinergic medication use on delirium severity, and APOE status did not moderate any outcomes. Greater use of clinically relevant anticholinergic medications was related to longer length of stay but not discharge disposition. CONCLUSIONS: For vulnerable older adults, anticholinergic exposure represents a potentially modifiable risk factor for poor attention, working memory, physical function, and greater length of stay during rehabilitation.Item Antidepressant Use and Depressive Symptoms in Intensive Care Unit Survivors(SHM, 2017) Wang, Sophia; Mosher, Chris; Gao, Sujuan; Kirk, Kayla; Lasiter, Sue; Khan, Sikandar; Kheir, You Na; Boustani, Malaz; Khan, Babar; Psychiatry, School of MedicineNearly 30% of intensive care unit (ICU) survivors have depressive symptoms 2-12 months after hospital discharge. We examined the prevalence of depressive symptoms and risk factors for depressive symptoms in 204 patients at their initial evaluation in the Critical Care Recovery Center (CCRC), an ICU survivor clinic based at Eskenazi Hospital in Indianapolis, Indiana. Thirty-two percent (N = 65) of patients had depressive symptoms on initial CCRC visit. For patients who are not on an antidepressant at their initial CCRC visit (N = 135), younger age and lower education level were associated with a higher likelihood of having depressive symptoms. For patients on an antidepressant at their initial CCRC visit (N = 69), younger age and being African American race were associated with a higher likelihood of having depressive symptoms. Future studies will need to confirm these findings and examine new approaches to increase access to depression treatment and test new antidepressant regimens for post-ICU depression.Item Assessing the Cost-effectiveness of a Hypothetical Disease-modifying Therapy With Limited Duration for the Treatment of Early Symptomatic Alzheimer Disease(Elsevier, 2022-11) Boustani, Malaz; Doty, Erin G.; Garrison, Louis P., Jr.; Smolen, Lee J.; Belger, Mark; Klein, Timothy M.; Murphy, Daniel R.; Burge , Russel; Wall , J. K.; Johnston, Joseph A.; Medicine, School of MedicinePurpose: Clinical trials have produced promising results for disease-modifying therapies (DMTs) for Alzheimer's disease (AD); however, the evidence on their potential cost-effectiveness is limited. This study assesses the cost-effectiveness of a hypothetical DMT with a limited treatment duration in AD. Methods: We developed a Markov state-transition model to estimate the cost-effectiveness of a hypothetical DMT plus best supportive care (BSC) versus BSC alone among Americans living with mild cognitive impairment (MCI) due to AD or mild AD. AD states included MCI due to AD, mild AD, moderate AD, severe AD, and death. A hypothetical DMT was assumed to confer a 30% reduction in progression from MCI and mild AD. The base case annual drug acquisition cost was assumed to be $56,000. Other medical and indirect costs were obtained from published literature or list prices. Utilities for patients and caregivers were obtained from the published literature and varied by AD state and care setting (community care or long-term care). We considered 3 DMT treatment strategies: (1) treatment administered until patients reached severe AD (continuous strategy), (2) treatment administered for a maximum duration of 18 months or when patients reached severe AD (fixed-duration strategy), and (3) 40% of patients discontinuing treatment at 6 months because of amyloid plaque clearance and the remaining patients continuing treatment until 18 months or until they reached severe AD (test-and-discontinue strategy). Incremental cost-effectiveness ratios (ICERs) were calculated as the incremental cost per quality-adjusted life-year (QALY) gained. Findings: From the health care sector perspective, continuous treatment with a hypothetical DMT versus BSC resulted in an ICER of $612,354 per QALY gained. The ICER decreased to $157,288 per QALY gained in the fixed-duration strategy, driven by large reductions in treatment costs. With 40% of patients discontinuing treatment at 6 months (test-and-discontinue strategy), the ICER was $125,631 per QALY gained. In sensitivity and scenario analyses, the ICER was the most sensitive to changes in treatment efficacy, treatment cost, and the initial population AD state distribution. From the modified societal perspective, ICERs were 6.3%, 20.4%, and 25.1% lower than those from the health care sector perspective for the continuous, fixed-duration, and test-and-discontinue strategies, respectively. Implications: Under a set of assumptions for annual treatment costs and the magnitude and duration of treatment efficacy, DMTs used for a limited duration may deliver value consistent with accepted US cost-effectiveness thresholds.Item Association Between Anticholinergic Medication Use and Cognition, Brain Metabolism, and Brain Atrophy in Cognitively Normal Older Adults(American Medical Association, 2016-06-01) Risacher, Shannon Leigh; McDonald, Brenna C.; Tallman, Eileen F.; West, John D.; Farlow, Martin R.; Unverzagt, Fredrick W.; Gao, Sujuan; Boustani, Malaz; Crane, Paul K.; Petersen, Ronald C.; Jack, Clifford R.; Jagust, William J.; Aisen, Paul S.; Weiner, Michael W.; Saykin, Andrew J.; Department of Radiology and Imaging Sciences, School of MedicineIMPORTANCE: The use of anticholinergic (AC) medication is linked to cognitive impairment and an increased risk of dementia. To our knowledge, this is the first study to investigate the association between AC medication use and neuroimaging biomarkers of brain metabolism and atrophy as a proxy for understanding the underlying biology of the clinical effects of AC medications. OBJECTIVE: To assess the association between AC medication use and cognition, glucose metabolism, and brain atrophy in cognitively normal older adults from the Alzheimer's Disease Neuroimaging Initiative (ADNI) and the Indiana Memory and Aging Study (IMAS). DESIGN, SETTING, AND PARTICIPANTS: The ADNI and IMAS are longitudinal studies with cognitive, neuroimaging, and other data collected at regular intervals in clinical and academic research settings. For the participants in the ADNI, visits are repeated 3, 6, and 12 months after the baseline visit and then annually. For the participants in the IMAS, visits are repeated every 18 months after the baseline visit (402 cognitively normal older adults in the ADNI and 49 cognitively normal older adults in the IMAS were included in the present analysis). Participants were either taking (hereafter referred to as the AC+ participants [52 from the ADNI and 8 from the IMAS]) or not taking (hereafter referred to as the AC- participants [350 from the ADNI and 41 from the IMAS]) at least 1 medication with medium or high AC activity. Data analysis for this study was performed in November 2015. MAIN OUTCOMES AND MEASURES: Cognitive scores, mean fludeoxyglucose F 18 standardized uptake value ratio (participants from the ADNI only), and brain atrophy measures from structural magnetic resonance imaging were compared between AC+ participants and AC- participants after adjusting for potential confounders. The total AC burden score was calculated and was related to target measures. The association of AC use and longitudinal clinical decline (mean [SD] follow-up period, 32.1 [24.7] months [range, 6-108 months]) was examined using Cox regression. RESULTS: The 52 AC+ participants (mean [SD] age, 73.3 [6.6] years) from the ADNI showed lower mean scores on Weschler Memory Scale-Revised Logical Memory Immediate Recall (raw mean scores: 13.27 for AC+ participants and 14.16 for AC- participants; P = .04) and the Trail Making Test Part B (raw mean scores: 97.85 seconds for AC+ participants and 82.61 seconds for AC- participants; P = .04) and a lower executive function composite score (raw mean scores: 0.58 for AC+ participants and 0.78 for AC- participants; P = .04) than the 350 AC- participants (mean [SD] age, 73.3 [5.8] years) from the ADNI. Reduced total cortical volume and temporal lobe cortical thickness and greater lateral ventricle and inferior lateral ventricle volumes were seen in the AC+ participants relative to the AC- participants. CONCLUSIONS AND RELEVANCE: The use of AC medication was associated with increased brain atrophy and dysfunction and clinical decline. Thus, use of AC medication among older adults should likely be discouraged if alternative therapies are available.Item Association Between Quality of Life and Depression in Dyads of Older Primary Care Patients and Family Members(Oxford University Press, 2022-12-20) Fowler, Nicole; Perkins, Anthony; Park, Seho; Schroeder, Matthew; Boustani, Malaz; School of NursingFamilial dyads experience illness as an interdependent unit. We evaluate the association of quality of life (QOL), as measured by physical (PCS) and mental health component (MCS) scores, with depression in dyads of older primary care patients and a family member. This is a cross sectional, descriptive study where QOL and depression were measured concurrently in the dyad using baseline data from 1809 dyads enrolled in a trial testing the benefits and harms of Alzheimer’s disease and related dementias (ADRD) screening. QOL was measured with the SF-36, depression was measured with the PHQ-9, and the association of depression with QOL was examined using an actor-partner interdependence model with distinguishable dyads. Patient mean (SD) age was 73.7 (5.7) years; 53.1% women; 85.1% white; 13.4% black. Family member mean (SD) age was 64.2 (13) years; 67.7% women; 13.4% black. A patient’s spouse/partner were 64.8% of family members. After controlling for dyadic relationship and gender, significant actor effects of depression on PCS for patient (β= -1.39; p< 0.001) and family member (β =-0.954; p< 0.001), and significant partner effects of depression on PCS for patient (β=-0.15, p< 0.05) and family member (β =-0.18; p< 0.01). There were significant actor effects of depression on MCS for patient (β =-1.2; p< 0.001) and family member (β=-1.2; p< 0.001), but depression had a significant partner effect on MCS only for patient (β = -0.08; p< 0.05). Among dyads participating in an ADRD screening trial, dyads with higher depression had lower QOL. Family member depression was associated with decreased family member and patient QOL.Item Becoming an Agile Change Conductor(Frontiers, 2022) Mehta, Jade; Aalsma, Matthew C.; O'Brien, Andrew; Boyer, Tanna J.; Ahmed, Rami A.; Summanwar, Diana; Boustani, Malaz; Family Medicine, School of MedicineBackground: It takes decades and millions of dollars for a new scientific discovery to become part of clinical practice. In 2015, the Center for Health Innovation & Implementation Science (CHIIS) launched a Professional Certificate Program in Innovation and Implementation Sciences aimed at transforming healthcare professionals into Agile Change Conductors capable of designing, implementing, and diffusing evidence-based healthcare solutions. Method: In 2022, the authors surveyed alumni from the 2016–2021 cohorts of the Certificate Program as part of an educational quality improvement inquiry and to evaluate the effectiveness of the program. Results: Of the 60 alumni contacted, 52 completed the survey (87% response rate) with 60% of graduates being female while 30% were an under-represented minority. On a scale from 1 to 5, the graduates agreed that the certificate benefited their careers (4.308 with a standard deviation (SD) of 0.612); expanded their professional network (4.615, SD of 0.530); and had a large impact on the effectiveness of their leadership (4.288, SD of 0.667), their change management (4.365, SD of 0.742), and their communication (4.392, SD of 0.666). Graduates claimed to use Agile Processes (Innovation, Implementation, or Diffusion), storytelling, and nudging weekly. On a scale from 0 to 10 where 10 indicates reaching a mastery, the average score for different Agile competencies ranged from 5.37 (SD of 2.80) for drafting business proposals to 7.77 (SD of 1.96) for self-awareness. For the 2020 and 2021 cohorts with existing pre and post training competency data, 22 of the 26 competencies saw a statistically significant increase. Conclusion: The Graduate Certificate has been able to create a network of Agile Change Conductors competent to design, implement, and diffuse evidence-based care within the healthcare delivery system. Further improvements in building dissemination mastery and program expansion initiatives are advised.Item Comparative Implementation of a Brief App-Directed Protocol for Delirium Identification by Hospitalists, Nurses, and Nursing Assistants : A Cohort Study(American College of Physicians, 2022) Marcantonio, Edward R.; Fick, Donna M.; Jung, Yoojin; Inouye, Sharon K.; Boltz, Marie; Leslie, Douglas L.; Husser, Erica K.; Shrestha, Priyanka; Moore, Amber; Sulmonte, Kimberlyann; Siuta, Jonathan; Boustani, Malaz; Ngo, Long H.; Medicine, School of MedicineBackground: Systematic screening improves delirium identification among hospitalized older adults. Little data exist on how to implement such screening. Objective: To test implementation of a brief app-directed protocol for delirium identification by physicians, nurses, and certified nursing assistants (CNAs) in real-world practice relative to a research reference standard delirium assessment (RSDA). Design: Prospective cohort study. Setting: Large urban academic medical center and small rural community hospital. Participants: 527 general medicine inpatients (mean age, 80 years; 35% with preexisting dementia) and 399 clinicians (53 hospitalists, 236 nurses, and 110 CNAs). Measurements: On 2 study days, enrolled patients had an RSDA. Subsequently, CNAs performed an ultra-brief 2-item screen (UB-2) for delirium, whereas physicians and nurses performed a 2-step protocol consisting of the UB-2 followed in those with a positive screen result by the 3-Minute Diagnostic Assessment for the Confusion Assessment Method. Results: Delirium was diagnosed in 154 of 924 RSDAs (17%) and in 114 of 527 patients (22%). The completion rate for clinician protocols exceeded 97%. The CNAs administered the UB-2 in a mean of 62 seconds (SD, 51). The 2-step protocols were administered in means of 104 seconds (SD, 99) by nurses and 106 seconds (SD, 105) by physicians. The UB-2 had sensitivities of 88% (95% CI, 72% to 96%), 87% (CI, 73% to 95%), and 82% (CI, 65% to 91%) when administered by CNAs, nurses, and physicians, respectively, with specificities of 64% to 70%. The 2-step protocol had overall accuracy of 89% (CI, 83% to 93%) and 87% (CI, 81% to 91%), with sensitivities of 65% (CI, 48% to 79%) and 63% (CI, 46% to 77%) and specificities of 93% (CI, 88% to 96%) and 91% (CI, 86% to 95%), for nurses and physicians, respectively. Two-step protocol sensitivity for moderate to severe delirium was 78% (CI, 54% to 91%). Limitation: Two sites; limited diversity. Conclusion: An app-directed protocol for delirium identification was feasible, brief, and accurate, and CNAs and nurses performed as well as hospitalists.