All Publications

  • "Like not having an arm": a qualitative study of the impact of visitor restrictions on cancer care during the COVID-19 pandemic. Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer Holdsworth, L. M., Siden, R., Wong, B. O., Verano, M., Lessios, A. S., Tabor, H. K., Schapira, L., Aslakson, R. 2024; 32 (5): 288


    Visitor restriction policies to prevent the spread of COVID-19 among patients and clinicians were widespread during the pandemic, resulting in the exclusion of caregivers at key points of cancer care and treatment decision-making. The aim of this study was to explore how visitor restrictions impacted cancer treatment decision-making and care from patient and physician perspectives.Sixty-seven interviews, including 48 cancer patients and 19 cancer and palliative care physicians from four academic cancer centers in the USA between August 2020 and July 2021.Visitor restrictions that prevented caregivers from participating in clinic appointments and perioperative hospital care created challenges in cancer care that spanned three domains: practical, social, and informational. We identified eight themes that characterized challenges within the three domains across all three groups, and that these challenges had negative emotional and psychological consequences for both groups. Physicians perceived that patients' negative experiences due to lack of support through the physical presence of caregivers may have worsened patient outcomes.Our data demonstrate the tripartite structure of the therapeutic relationship in cancer care with caregivers providing critical support in the decision-making and care process to both patients and physicians. Caregiver absences led to practical, psychosocial, and informational burdens on both groups, and likely increased the risk of burnout among physicians. Our findings suggest that the quality of cancer care can be enhanced by engaging caregivers and promoting their physical presence during clinical encounters.

    View details for DOI 10.1007/s00520-024-08473-8

    View details for PubMedID 38622350

    View details for PubMedCentralID PMC11018646

  • Analysis of FRAME data (A-FRAME): An analytic approach to assess the impact of adaptations on health services interventions and evaluations. Learning health systems Mui, H. Z., Brown-Johnson, C. G., Saliba-Gustafsson, E. A., Lessios, A. S., Verano, M., Siden, R., Holdsworth, L. M. 2024; 8 (1): e10364


    Tracking adaptations during implementation can help assess and interpret outcomes. The framework for reporting adaptations and modifications-expanded (FRAME) provides a structured approach to characterize adaptations. We applied the FRAME across multiple health services projects, and developed an analytic approach to assess the impact of adaptations.Mixed methods analysis of research diaries from seven quality improvement (QI) and research projects during the early stages of the COVID-19 pandemic. Using the FRAME as a codebook, discrete adaptations were described and categorized. We then conducted a three-step analysis plan: (1) calculated the frequency of adaptations by FRAME categories across projects; (2) qualitatively assessed the impact of adaptations on project goals; and (3) qualitatively assessed relationships between adaptations within projects to thematically consolidate adaptations to generate more explanatory value on how adaptations influenced intervention progress and outcomes.Between March and July 2020, 42 adaptations were identified across seven health services projects. The majority of adaptations related to training or evaluation (52.4%) with the goal of maintaining the feasibility (66.7%) of executing projects during the pandemic. Five FRAME constructs offered the most explanatory benefit to assess the impact of adaptations on program and evaluation goals, providing the basis for creating an analytic approach dubbed the "A-FRAME," analysis of FRAME data. Using the A-FRAME, the 42 adaptations were consolidated into 17 succinct adaptations. Two QI projects discontinued altogether. Intervention adaptations related to staffing, training, or delivery, while evaluation adaptations included design, recruitment, and data collection adjustments.By sifting qualitative data about adaptations into the A-FRAME, implementers and researchers can succinctly describe how adaptations affect interventions and their evaluations. The simple and concise presentation of information using the A-FRAME matrix can help implementers and evaluators account for the influence of adaptations on program outcomes.

    View details for DOI 10.1002/lrh2.10364

    View details for PubMedID 38249838

    View details for PubMedCentralID PMC10797575

  • A Nurse-Led Care Delivery App and Telehealth System for Patients Requiring Wound Care: Mixed Methods Implementation and Evaluation Study. JMIR formative research Brown-Johnson, C. G., Lessios, A. S., Thomas, S., Kim, M., Fukaya, E., Wu, S., Kling, S. M., Brown, G., Winget, M. 2023; 7: e43258


    Innovative solutions to nursing care are needed to address nurse, health system, patient, and caregiver concerns related to nursing wellness, work flexibility and control, workforce retention and pipeline, and access to patient care. One innovative approach includes a novel health care delivery model enabling nurse-led, off-hours wound care (PocketRN) to triage emergent concerns and provide additional patient health education via telehealth.This pilot study aimed to evaluate the implementation of PocketRN from the perspective of nurses and patients.Patients and part-time or per-diem, wound care-certified and generalist nurses were recruited through the Stanford Medicine Advanced Wound Care Center in 2021 and 2022. Qualitative data included semistructured interviews with nurses and patients and clinical documentation review. Quantitative data included app use and brief end-of-interaction in-app satisfaction surveys.This pilot study suggests that an app-based nursing care delivery model is acceptable, clinically appropriate, and feasible. Low technology literacy had a modest effect on initial patient adoption; this barrier was addressed with built-in outreach and by simplifying the patient experience (eg, via phone instead of video calls). This approach was acceptable for users, despite total patient enrollment and use numbers being lower than anticipated (N=49; 17/49, 35% of patients used the app at least once beyond the orientation call). We interviewed 10 patients: 7 who had used the app were satisfied with it and reported that real-time advice after hours reduced anxiety, and 3 who had not used the app after enrollment reported having other resources for health care advice and noted their perception that this tool was meant for urgent issues, which did not occur for them. Interviewed nurses (n=10) appreciated working from home, and they reported comfort with the scope of practice and added quality of care facilitated by video capabilities; there was interest in additional wound care-specific training for nonspecialized nurses. Nurses were able to provide direct patient care over the web, including the few participating nurses who were unable to perform in-person care (n=2).This evaluation provides insights into the integration of technology into standard health care services, such as in-clinic wound care. Using in-system nurses with access to electronic medical records and specialized knowledge facilitated app integration and continuity of care. This care delivery model satisfied nurse desires for flexible and remote work and reduced patient anxiety, potentially reducing postoperative wound care complications. Feasibility was negatively impacted by patients' technology literacy and few language options; additional patient training, education, and language support are needed to support equitable access. Adoption was impacted by a lack of perceived need for additional care; lower-touch or higher-acuity settings with a longer wait between visits could be a better fit for this type of nurse-led care.

    View details for DOI 10.2196/43258

    View details for PubMedID 37610798

  • Caregiver Experiences Participating in a Home-Based Primary Care Program: A Pragmatic Evaluation Including Qualitative Interviews and Quantitative Surveys. Journal of applied gerontology : the official journal of the Southern Gerontological Society Kling, S. M., Lessios, A. S., Holdsworth, L. M., Yefimova, M., Wu, S., Martin, M., Sheffrin, M., Winget, M. 2023: 7334648231176380


    The aim of this evaluation was to assess caregiver experience and burden during their first year in a geriatric home-based primary care (HBPC) program with qualitative interviews and surveys. HBPC included in-home visits for homebound, older adult patients. Seventeen caregivers, with varied amount of experience with HBPC, participated in semi-structured interviews. Change in caregiver burden from baseline was captured for 44 caregivers at 3months post-enrollment, 27 caregivers at 6months, and 22 caregivers at 12months. Satisfaction survey was administered at these timepoints, but the last response of 48 caregivers was analyzed. Caregiver interviews revealed three themes: caregiving stressors, reliance on HBPC in relation to other medical care, and healthcare in the home. Surveyed caregivers were highly satisfied, but burden did not change substantially over the 1year intervention. Caregivers appreciated HBPC reduced patient transportation and provided satisfactory primary care, but additional research is needed to tailor this care to reduce caregiver burden.

    View details for DOI 10.1177/07334648231176380

    View details for PubMedID 37269325

  • Effect of Perioperative Palliative Care on Health-Related Quality of Life Among Patients Undergoing Surgery for Cancer: A Randomized Clinical Trial. JAMA network open Aslakson, R. A., Rickerson, E., Fahy, B., Waterman, B., Siden, R., Colborn, K., Smith, S., Verano, M., Lira, I., Hollahan, C., Siddiqi, A., Johnson, K., Chandrashekaran, S., Harris, E., Nudotor, R., Baker, J., Heidari, S. N., Poultsides, G., Conca-Cheng, A. M., Cook Chapman, A., Lessios, A. S., Holdsworth, L. M., Gustin, J., Ejaz, A., Pawlik, T., Miller, J., Morris, A. M., Tulsky, J. A., Lorenz, K., Temel, J. S., Smith, T. J., Johnston, F. 2023; 6 (5): e2314660


    Involvement of palliative care specialists in the care of medical oncology patients has been repeatedly observed to improve patient-reported outcomes, but there is no analogous research in surgical oncology populations.To determine whether surgeon-palliative care team comanagement, compared with surgeon team alone management, improves patient-reported perioperative outcomes among patients pursuing curative-intent surgery for high morbidity and mortality upper gastrointestinal (GI) cancers.From October 20, 2018, to March 31, 2022, a patient-randomized clinical trial was conducted with patients and clinicians nonblinded but the analysis team blinded to allocation. The trial was conducted in 5 geographically diverse academic medical centers in the US. Individuals pursuing curative-intent surgery for an upper GI cancer who had received no previous specialist palliative care were eligible. Surgeons were encouraged to offer participation to all eligible patients.Surgeon-palliative care comanagement patients met with palliative care either in person or via telephone before surgery, 1 week after surgery, and 1, 2, and 3 months after surgery. For patients in the surgeon-alone group, surgeons were encouraged to follow National Comprehensive Cancer Network-recommended triggers for palliative care consultation.The primary outcome of the trial was patient-reported health-related quality of life at 3 months following the operation. Secondary outcomes were patient-reported mental and physical distress. Intention-to-treat analysis was performed.In total, 359 patients (175 [48.7%] men; mean [SD] age, 64.6 [10.7] years) were randomized to surgeon-alone (n = 177) or surgeon-palliative care comanagement (n = 182), with most patients (206 [57.4%]) undergoing pancreatic cancer surgery. No adverse events were associated with the intervention, and 11% of patients in the surgeon-alone and 90% in the surgeon-palliative care comanagement groups received palliative care consultation. There was no significant difference between study arms in outcomes at 3 months following the operation in patient-reported health-related quality of life (mean [SD], 138.54 [28.28] vs 136.90 [28.96]; P = .62), mental health (mean [SD], -0.07 [0.87] vs -0.07 [0.84]; P = .98), or overall number of deaths (6 [3.7%] vs 7 [4.1%]; P > .99).To date, this is the first multisite randomized clinical trial to evaluate perioperative palliative care and the earliest integration of palliative care into cancer care. Unlike in medical oncology practice, the data from this trial do not suggest palliative care-associated improvements in patient-reported outcomes among patients pursuing curative-intent surgeries for upper GI Identifier: NCT03611309.

    View details for DOI 10.1001/jamanetworkopen.2023.14660

    View details for PubMedID 37256623

  • Analysis of FRAME data (A-FRAME): An analytic approach to assess the impact of adaptations on health services interventions and evaluations LEARNING HEALTH SYSTEMS Mui, H. Z., Brown-Johnson, C. G., Saliba-Gustafsson, E. A., Lessios, A., Verano, M., Siden, R., Holdsworth, L. M. 2023

    View details for DOI 10.1002/lrh2.10364

    View details for Web of Science ID 000952417800001

  • "It Isn't the Same": Experiences of Informal Caregivers of Older Adults Enrolled in a Home-Based Senior Care Program During COVID-19. Journal of gerontological nursing Humber, M. B., Yefimova, M., Lessios, A. S., Trivedi, R. B., Sheffrin, M., Martin, M. 2023; 49 (3): 19-26


    The coronavirus disease 2019 (COVID-19) pandemic placed new strains on informal caregivers, who are already vulnerable to negative psychosocial effects due to demands of the caregiving role. The current study aimed to explore the early impact of COVID-19 on caregivers living with and apart from care recipients. Semi-structured qualitative interviews with seven cohabitating and 10 distanced caregivers of patients in a home-based primary care program were conducted from April to November 2020. A framework matrix was used to identify patterns in caregiver experiences. Cohabitating and distanced caregivers reported shared concerns about COVID-19 and unique concerns dependent on cohabitation status. Cohabitating caregivers reported financial worries, care recipients with dementia being unable to understand restrictions, and concerns about community business changes. Distanced caregivers reported communication challenges with cognitively impaired care recipients and challenges with visitation policies. During pandemics, caregivers' clinical and policy support needs may differ depending on their place of residence relative to care recipients. [Journal of Gerontological Nursing, 49(3), 19-26.].

    View details for DOI 10.3928/00989134-20230209-04

    View details for PubMedID 36852991

  • Home-Based Primary Care for Older Adults: Matched Case-Control Evaluation of Program's Impact on Healthcare Utilization HOME HEALTH CARE MANAGEMENT AND PRACTICE Kling, S. R., Garvert, D. W., Lessios, A., Yefimova, M., Martin, M., Sheffrin, M., Winget, M. 2023
  • A 360 degree mixed-methods evaluation of a specialized COVID-19 outpatient clinic and remote patient monitoring program. BMC primary care Vilendrer, S., Lestoquoy, A., Artandi, M., Barman, L., Cannon, K., Garvert, D. W., Halket, D., Holdsworth, L. M., Singer, S., Vaughan, L., Winget, M. 2022; 23 (1): 151


    BACKGROUND: Our goals are to quantify the impact on acute care utilization of a specialized COVID-19 clinic with an integrated remote patient monitoring program in an academic medical center and further examine these data with stakeholder perceptions of clinic effectiveness and acceptability.METHODS: A retrospective cohort was drawn from enrolled and unenrolled ambulatory patients who tested positive in May through September 2020 matched on age, presence of comorbidities and other factors. Qualitative semi-structured interviews with patients, frontline clinician, and administrators were analyzed in an inductive-deductive approach to identify key themes.RESULTS: Enrolled patients were more likely to be hospitalized than unenrolled patients (N=11/137 in enrolled vs 2/126 unenrolled, p=.02), reflecting a higher admittance rate following emergency department (ED) events among the enrolled vs unenrolled, though this was not a significant difference (46% vs 25%, respectively, p=.32). Thirty-eight qualitative interviews conducted June to October 2020 revealed broad stakeholder belief in the clinic's support of appropriate care escalation. Contrary to beliefs the clinic reduced inappropriate care utilization, no difference was seen between enrolled and unenrolled patients who presented to the ED and were not admitted (N=10/137 in enrolled vs 8/126 unenrolled, p=.76). Administrators and providers described the clinic's integral role in allowing health services to resume in other areas of the health system following an initial lockdown.CONCLUSIONS: Acute care utilization and multi-stakeholder interviews suggest heightened outpatient observation through a specialized COVID-19 clinic and remote patient monitoring program may have contributed to an increase in appropriate acute care utilization. The clinic's role securing safe reopening of health services systemwide was endorsed as a primary, if unmeasured, benefit.

    View details for DOI 10.1186/s12875-022-01734-7

    View details for PubMedID 35698064

  • Patient and surgeon experiences with video visits in plastic surgery-toward a data-informed scheduling triage tool. Surgery Brown-Johnson, C. G., Spargo, T., Kling, S. M., Saliba-Gustafsson, E. A., Lestoquoy, A. S., Garvert, D. W., Vilendrer, S., Winget, M., Asch, S. M., Maggio, P., Nazerali, R. S. 2021


    BACKGROUND: Coronavirus disease 2019 provided the impetus for unprecedented adoption of telemedicine. This study aimed to understand video visit adoption by plastic surgery providers; and patient and surgeon perceptions about its efficacy, value, accessibility, and long-term viability. A secondary aim was to develop the proposed 'Triage Tool for Video Visits in Plastic Surgery' to help determine visit video eligibility.METHODS: This mixed-methods evaluation assessed provider-level scheduling data from the Division of Plastic and Reconstructive Surgery at Stanford Health Care to quantify telemedicine adoption and semi-structured phone interviews with patients (n= 20) and surgeons (n= 10) to explore stakeholder perspectives on video visits.RESULTS: During the 13-week period after the local stay-at-home orders due to coronavirus disease 2019, 21.4% of preoperative visits and 45.5% of postoperative visits were performed via video. Video visits were considered acceptable by patients and surgeons in plastic surgery in terms of quality of care but were limited by the inability to perform a physical examination. Interviewed clinicians reported that long-term viability needs to be centered around technology (eg, connection, video quality, etc) and physical examinations. Our findings informed a proposed triage tool to determine the appropriateness of video visits for individual patients that incorporates visit type, anesthesia, case, surgeon's role, and patient characteristics.CONCLUSION: Video technology has the potential to facilitate and improve preoperative and postoperative patient care in plastic surgery but the following components are needed: patient education on taking high-quality photos; standardized clinical guidelines for conducting video visits; and an algorithm-assisted triage tool to support scheduling.

    View details for DOI 10.1016/j.surg.2021.03.029

    View details for PubMedID 33941389

  • Rapid implementation of video visits in neurology during COVID-19: a mixed methods evaluation. Journal of medical Internet research Saliba-Gustafsson, E. A., Miller-Kuhlmann, R. n., Kling, S. M., Garvert, D. W., Brown-Johnson, C. G., Lestoquoy, A. S., Verano, M. R., Yang, L. n., Falco-Walter, J. n., Shaw, J. G., Asch, S. M., Gold, C. A., Winget, M. n. 2020


    Telemedicine has been used for decades; yet, despite its many advantages, its uptake and rigorous evaluation of feasibility across neurology's ambulatory subspecialties has been sparse. The SARS-CoV-2 (COVID-19) pandemic however, prompted healthcare systems worldwide to reconsider traditional healthcare delivery. To safeguard healthcare workers and patients many healthcare systems quickly transitioned to telemedicine, including across neurology subspecialties, providing a new opportunity to evaluate this modality of care.To evaluate the accelerated implementation of video visits in ambulatory neurology during the COVID-19 pandemic, we used mixed methods to assess the adoption, acceptability, appropriateness, and perceptions of potential sustainability.Video visits were launched rapidly in ambulatory neurology clinics of a large academic medical center. To assess adoption, we analyzed clinician-level scheduling data collected between March 22 and May 16, 2020. We assessed acceptability, appropriateness, and sustainability via a clinician survey (n=48) and semi-structured interviews with providers (n=30) completed between March and May 2020.Video visits were adopted rapidly; 65 (98%) clinicians integrated video visits into their workflow within the first 6 implementation weeks and 92% of all visits were conducted via video. Video visits were largely considered acceptable by clinicians, although various technological issues impacted satisfaction. Video visits were reported to be more convenient for patients, families, and/or caregivers than in-person visits; however, access to technology, the patient's technological capacity, and language difficulties were considered barriers. Many clinicians expressed optimism about future utilization of video visits in neurology. They believed that video visits promote continuity of care and can be incorporated into their practice long-term, although several insisted that they can never replace the in-person examination.Video visits are an important addition to clinical care in ambulatory neurology and are anticipated to remain a permanent supplement to in-person visits, promoting patient care continuity, and flexibility for patients and clinicians alike.

    View details for DOI 10.2196/24328

    View details for PubMedID 33245699



    Description of recruitment methods and lessons learned in a randomized controlled trial of underserved patients using an integrative medical group visits intervention.Comparison of the demographic characteristics of participants screened and consented to the study as well as description of recruitment methods used.This paper examines the characteristics of patients who were eligible compared to those who were not, characteristics of patients at the different sites, and patient characteristics over time (by comparing various cohorts) based on our experiences recruiting underserved patients.We screened 338 patients, with 205 (60.6%) meeting eligibility criteria and 159 patients randomized and consented. 133 patients were found ineligible, with the most common reasons being low depression scores (n = 20), manic symptoms (n = 20), and psychotic symptoms (n = 19), and alcohol use (n = 15). We found demographic differences in patients recruited by different methods and at different sites- patients referred by provider letter were older than those referred by self-referral or provider referral (mean age/SD vs. mean age/SD, p = 0.0001). For site-specific differences, patients at DH were older (53 SD = 12.3) than those at the Boston Medical Center (49 SD = 11.3) and CSHC (p = 0.048) in pair-wise comparisons. Patients at DH were also more likely to be white (25%) as compared to BMC (18%) and DH (7%), while those at CSHC were more likely to be black (70%) (p = 0.008).

    View details for DOI 10.1016/j.explore.2019.01.003

    View details for Web of Science ID 000474328500008

    View details for PubMedID 31056423

  • Health Disparities in Access to Nonpharmacologic Therapies in an Urban Community JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE Cheng, T., D'Amico, S., Luo, M., Lestoquoy, A., Yinusa-Nyahkoon, L., Laird, L. D., Gardiner, P. M. 2019; 25 (1): 48–60


    The overuse of prescription opioids for chronic pain is recognized as a public health crisis. Yet, poor access to nonpharmacologic treatments is the norm in low-income, racially and ethnically diverse patients with chronic pain. The main objective of this study was to understand how chronic pain impacts low-income individuals with chronic pain and their communities from multiple perspectives.This was a qualitative study using a Science Café methodology.The Science Café event was held at an urban community center in Boston, MA.Inclusion criteria included the following: having the ability to attend the event, being at least 18 years of age or older, and participating in English.Data were collected through self-reported questionnaires and audio or video recordings of two focus groups. Quantitative and qualitative data were analyzed with SAS 9.3 and NVivo 10.Thirty participants attended the Science Café event. The average age was 45 years, 77% reported as female, 42% identified as black, and 19% as Hispanic. Participants identified themselves as either patients (46%) or providers (54%) to the chronic pain community. Our forum revealed three major themes: (1) nonpharmacologic options for chronic pain management are warranted, (2) larger sociodemographic and contextual factors influence management of chronic pain, and (3) both patients and providers value the patient-provider relationship and acknowledge the need for better communication for patients with chronic pain.Future research should consider identifying and addressing disparities in access to nonpharmacologic treatments for chronic pain in relation to underlying social determinants of health, particularly for racially and ethnically diverse patients.

    View details for DOI 10.1089/acm.2018.0217

    View details for Web of Science ID 000445089600001

    View details for PubMedID 30234363

  • The Latino Integrative Medical Group Visit as a Model for Pain Reduction in Underserved Spanish Speakers JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE Cornelio-Flores, O., Lestoquoy, A., Abdallah, S., DeLoureiro, A., Lorente, K., Pardo, B., Olunwa, J., Gardiner, P. 2018; 24 (2): 125–31


    Chronic pain is a common problem in the United States, one for which there is a dearth of effective treatments. Nonpharmacological options are a promising alternative, especially for Spanish-speaking Latinos. This pilot study would like to assess the feasibility of an adapted Integrative Medical Group Visit (IMGV) curriculum for a Spanish-speaking Latino chronic pain population.We translated and adapted the curriculum of the IMGV for a Spanish-speaking Latino chronic pain population. We then tested the feasibility of using this model with two pilot groups (N = 19) using a pre-postdesign.This intervention was targeted for underserved Spanish-speaking Latino patients with chronic pain.This study took place at a safety net academic teaching hospital, the Boston Medical Center, and at a community health center located in a majority Latino neighborhood, the East Boston Neighborhood Health Clinic.We used the validated Spanish translations of the Patient-Reported Outcomes Measurement Information System (PROMIS-29) (short version), Personal Health Questionnaire (PHQ-8), and Perceived Stress Scale (PSS-10). We also gathered qualitative information through focus groups and in-depth interviews.Using PROMIS measures, there was a statistically significant reduction in pain interference (p = 0.01), fatigue (p = 0.01), and depression (p = 0.01). Qualitative data also indicated the participants felt they benefited from the visits and having care in Spanish was unique.This model offers a promising nonpharmacological option for Spanish-speaking patients with chronic pain and could offer an alternative for addressing disparities for this population.

    View details for DOI 10.1089/acm.2017.0132

    View details for Web of Science ID 000424783100006

    View details for PubMedID 28885858

  • Living with chronic pain: Evaluating patient experiences with a medical group visit focused on mindfulness and non-pharmacological strategies COMPLEMENTARY THERAPIES IN MEDICINE Lestoquoy, A., Laird, L. D., Mitchell, S., Gergen-Bamett, K., Negash, N., McCue, K., Enad, R., Gardiner, P. 2017; 35: 33–38


    Little is known about the acceptance of non-pharmacological group strategies delivered to low income racially diverse patients with chronic pain and depression. This paper examines how the Integrative Medical Group Visit (IMGV) addresses many of the deficits identified with usual care.Six IMGVs cohorts were held at a safety net hospital and two federally funded community health centres. Data was gathered through focus groups. Transcripts were analysed using both a priori codes and inductive coding.The intervention included ten sessions of Integrative Medical Group Visits with a primary care provider and a meditation instructor. The curriculum uses principles of Mindfulness Based Stress Reduction and evidence based integrative medicine. The visit is structured similarly to other group medical visits.Data was gathered through four focus groups held after the cohorts were completed.Participants (N=20) were largely low income minority adults with chronic pain and comorbid depression. Six themes emerged from the coding including: chronic pain is isolating; group treatment contributes to better coping with pain; loss of control and autonomy because of the unpredictability of pain as well as dependence on medication and frequent medical appointments; groups improve agency and control over one's health condition; navigating the healthcare system and unsatisfactory treatment options; and changes after the IMGV due to non-pharmacological health management.The IMGV is a promising format of delivering integrative care for chronic pain and depression which addresses many of the problems identified by patients in usual care.

    View details for DOI 10.1016/j.ctim.2017.09.002

    View details for Web of Science ID 000418221800007

    View details for PubMedID 29154064

  • Design of the integrative medical group visits randomized control trial for underserved patients with chronic pain and depression CONTEMPORARY CLINICAL TRIALS Gardiner, P., Lestoquoy, A., Gergen-Barnett, K., Penti, B., White, L. F., Saper, R., Fredman, L., Stillman, S., Negash, N., Adelstein, P., Brackup, I., Farrell-Riley, C., Kabbara, K., Laird, L., Mitchell, S., Bickmore, T., Shamekhi, A., Liebschutz, J. M. 2017; 54: 25–35


    Given the public health crisis of opioid overprescribing for pain, there is a need for evidence-based non pharmacological treatment options that effectively reduce pain and depression. We aim to examine the effectiveness of the Integrative Medical Group Visits (IMGV) model in reducing chronic pain and depressive symptoms, as well as increasing pain self-management.This paper details the study design and implementation of an ongoing randomized controlled trial of the IMGV model as compared to primary care visits. The research aims to determine if the IMGV model is effective in achieving: a) a reduction in self-reported pain and depressive symptoms and 2) an improvement in the self-management of pain, through increasing pain self-efficacy and reducing use of self-reported pain medication. We intend to recruit 154 participants to be randomized in our intervention, the IMGV model (n=77) and to usual care (n=77).Usual care of chronic pain through pharmacological treatment has mixed evidence of efficacy and may not improve quality of life or functional status. We aim to conduct a randomized controlled trial to evaluate the effectiveness of the IMGV model as compared to usual care in reducing self-reported pain and depressive symptoms as well as increasing pain management skills.

    View details for DOI 10.1016/j.cct.2016.12.013

    View details for Web of Science ID 000394557500004

    View details for PubMedID 27979754

  • Augmenting Group Medical Visits with Conversational Agents for Stress Management Behavior Change Shamekhi, A., Bickmore, T., Lestoquoy, A., Gardiner, P., DeVries, P. W., OinasKukkonen, H., Siemons, L., BeerlageDeJong, N., VanGemertPijnen, L. SPRINGER INTERNATIONAL PUBLISHING AG. 2017: 55–67
  • Blissful Agents: Adjuncts to Group Medical Visits for Chronic Pain and Depression Shamekhi, A., Bickmore, T., Lestoquoy, A., Negash, L., Gardiner, P., Traum, D., Swartout, W., Khooshabeh, P., Kopp, S., Scherer, S., Leuski, A. SPRINGER-VERLAG BERLIN. 2016: 433–37
  • The Costs and Benefits of Reducing Racial-Ethnic Disparities in Mental Health Care PSYCHIATRIC SERVICES Le Cook, B., Liu, Z., Lessios, A., Loder, S., McGuire, T. 2015; 66 (4): 389–96


    Previous studies have found that timely mental health treatment can result in savings in both mental health and general medical care expenditures. This study examined whether reducing racial-ethnic disparities in mental health care offsets costs of care.Data were from a subsample of 6,206 individuals with probable mental illness from the 2004-2010 Medical Expenditure Panel Survey (MEPS). First, disparities in mental health treatment were analyzed. Second, two-year panel data were used to determine the offset of year 1 mental health outpatient and pharmacy treatment on year 2 mental and general medical expenditures. Third, savings were estimated by combining results from steps 1 and 2.Compared with whites, blacks and Latinos with year 1 outpatient mental health care spent less on inpatient and emergency general medical care in year 2. Latinos receiving mental health care in year 1 spent less than others on inpatient general medical care in year 2. Latinos taking psychotropic drugs in year 1 showed reductions in inpatient general medical care. Reducing racial-ethnic disparities in mental health care and in psychotropic drug use led to savings in acute medical care expenditures.Savings in acute care expenditures resulting from eliminating disparities in racial-ethnic mental health care access were greater than costs in some but not all areas of acute mental health and general medical care. For blacks and Latinos, the potential savings from eliminating disparities in inpatient general medical expenditures are substantial (as much as $1 billion nationwide), suggesting that financial and equity considerations can be aligned when planning disparity reduction programs.

    View details for DOI 10.1176/

    View details for Web of Science ID 000370687300010

    View details for PubMedID 25588417

    View details for PubMedCentralID PMC7595243

  • Effectiveness of the Engagement and Counseling for Latinos (ECLA) Intervention in Low-income Latinos MEDICAL CARE Alegria, M., Ludman, E., Kafali, E., Lapatin, S., Vila, D., Shrout, P. E., Keefe, K., Cook, B., Ault, A., Li, X., Bauer, A. M., Epelbaum, C., Alcantara, C., Pineda, T. G., Tejera, G. G., Suau, G., Leon, K., Lessios, A. S., Ramirez, R. R., Canino, G. 2014; 52 (11): 989–97


    Persistent disparities in access and quality of mental health care for Latinos indicate a need for evidence-based, culturally adapted, and outside-the-clinic-walls treatments.Evaluate treatment effectiveness of telephone (ECLA-T) or face-to-face (ECLA-F) delivery of a 6-8 session cognitive behavioral therapy and care management intervention for low-income Latinos, as compared to usual care for depression.Multisite randomized controlled trial.Eight community health clinics in Boston, Massachusetts and San Juan, Puerto Rico.257 Latino patients recruited from primary care between May 2011 and September 2012.The primary outcome was severity of depression, assessed with the Patient Health Questionnaire-9 and the Hopkins Symptom Checklist-20. The secondary outcome was functioning over the previous 30 days, measured using the World Health Organization Disability Assessment Schedule (WHO-DAS 2.0).Both telephone and face-to-face versions of the Engagement and Counseling for Latinos (ECLA) were more effective than usual care. The effect sizes of both intervention conditions on Patient Health Questionnaire-9 were moderate when combined data from both sites are analyzed (0.56 and 0.64 for face-to-face and telephone, respectively). Similarly, effect sizes of ECLA-F and ECLA-T on the Hopkins Symptom Checklist were quite large in the Boston site (0.64 and 0.73. respectively) but not in Puerto Rico (0.10 and 0.03).The intervention appears to help Latino patients reduce depressive symptoms and improve functioning. Of particular importance is the higher treatment initiation for the telephone versus face-to-face intervention (89.7% vs. 78.8%), which suggests that telephone-based care may improve access and quality of care.

    View details for DOI 10.1097/MLR.0000000000000232

    View details for Web of Science ID 000343930300009

    View details for PubMedID 25310525

    View details for PubMedCentralID PMC4201237

  • Activation, Self-management, Engagement, and Retention in Behavioral Health Care A Randomized Clinical Trial of the DECIDE Intervention JAMA PSYCHIATRY Alegria, M., Carson, N., Flores, M., Li, X., Shi, P., Lessios, A., Polo, A., Allen, M., Fierro, M., Interian, A., Jimenez, A., La Roche, M., Lee, C., Lewis-Fernandez, R., Livas-Stein, G., Safar, L., Schuman, C., Storey, J., Shrout, P. E. 2014; 71 (5): 557–65


    Given minority patients' unequal access to quality care, patient activation and self-management strategies have been suggested as a promising approach to improving mental health care.To determine whether the DECIDE (Decide the problem; Explore the questions; Closed or open-ended questions; Identify the who, why, or how of the problem; Direct questions to your health care professional; Enjoy a shared solution) intervention, an educational strategy that teaches patients to ask questions and make collaborative decisions with their health care professional, improves patient activation and self-management, as well as engagement and retention in behavioral health care.In this multisite randomized clinical trial performed from February 1, 2009, through October 9, 2011 (date of last follow-up interview), we recruited 647 English- or Spanish-speaking patients 18 to 70 years old from 13 outpatient community mental health clinics across 5 states and 1 US territory. A total of 722 patients were included in analyses of secondary outcomes.Three DECIDE training sessions delivered by a care manager vs giving patients a brochure on management of behavioral health.Primary outcomes were patient assessment of activation (Patient Activation Scale) and self-management (Perceived Efficacy in Patient-Physician Interactions). Secondary outcomes included patient engagement (proportion of visits attended of those scheduled) and retention (attending at least 4 visits in the 6 months after the baseline research assessment), collected through medical record review or electronic records.Patients assigned to DECIDE reported significant increases in activation (mean β = 1.74, SD = 0.58; P = .003) and self-management (mean β = 2.42, SD = 0.90; P = .008) relative to control patients, but there was no evidence of an effect on engagement or retention in care.The DECIDE intervention appears to help patients learn to effectively ask questions and participate in decisions about their behavioral health care, but a health care professional component might be needed to augment engagement in care. DECIDE appears to have promise as a strategy for changing the role of minority patients in behavioral health Identifier: NCT01226329

    View details for DOI 10.1001/jamapsychiatry.2013.4519

    View details for Web of Science ID 000335947600013

    View details for PubMedID 24647680

    View details for PubMedCentralID PMC4311517

  • Revisiting the evidence on health and health care disparities among the Roma: a systematic review 2003-2012 INTERNATIONAL JOURNAL OF PUBLIC HEALTH Cook, B., Wayne, G., Valentine, A., Lessios, A., Yeh, E. 2013; 58 (6): 885–911


    To conduct a systematic review of the epidemiological and health service utilization literature related to the Roma population between 2003 and 2012.Systematic review of empirical research related to Roma health and health care utilization published between 2003 and 2012 identified through electronic databases (PsycInfo, Medline, Google Scholar). Methodological rigor was evaluated using a six-point set of design criteria.We found evidence for lower self-reported health and significantly higher mortality risk for Roma compared to non-Roma, and greater prevalence of health risk factors for Roma children, including environmental risks, low birth weight, and lower vaccination coverage. Studies of non-communicable and infectious disease remain insufficient to make firm conclusions on disparities. Barriers to care include lack of documentation and affordability of care, though more studies on health care utilization are needed.Roma youth and adults are in need of programs that reduce health disparities and their increased mortality risk. Reducing exposure to risk factors such as smoking, obesity, and poor living conditions may be a target for interventions. More intervention studies and rigorous evaluations are needed.

    View details for DOI 10.1007/s00038-013-0518-6

    View details for Web of Science ID 000327858000011

    View details for PubMedID 24096986