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OBJECTIVE: To describe key features and the initial implementation of an employer-sponsored program designed to increase access to quality mental health treatment for employees of a large health care system. Methods: Retrospective data were collected on employer's efforts to develop a programmatic solution to address barriers to accessing quality mental health treatment among its employees and on initial program implementation. Results: Data from the initial cohort ( N = 1049) of program participants support the use of low threshold digital tools to enhance access to care, the importance of care navigation and a robust curated provider network in matching employees to appropriate care options, and the value of providing online, evidence-based psychotherapy to facilitate high rates of treatment engagement. Conclusions: Findings can help inform employers about approaches to improve access to quality mental health treatment for their employees.
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Accesibilidad a los Servicios de Salud , Servicios de Salud Mental , Humanos , Estudios Retrospectivos , Servicios de Salud Mental/normas , Masculino , Femenino , Adulto , Servicios de Salud del Trabajador , Persona de Mediana Edad , Personal de Salud , Mejoramiento de la Calidad , Trastornos Mentales/terapiaRESUMEN
BACKGROUND: The collaborative care model is a well-established system of behavioral health care within primary care settings. There is potential for mobile health (mHealth) technology to augment collaborative behavioral health care in primary care settings, thereby improving scalability, efficiency, and clinical outcomes. OBJECTIVE: We aimed to assess the feasibility of engaging with and the preliminary clinical outcomes of an mHealth platform that was used to augment an existing collaborative care program in primary care settings. METHODS: We performed a longitudinal, single-arm feasibility study of an mHealth platform that was used to augment collaborative care. A total of 3 behavioral health care managers, who were responsible for coordinating disease management in 6 primary care practices, encouraged participants to use a mobile app to augment the collaborative model of behavioral health care. The mHealth platform's functions included asynchronous chats with the behavioral health care managers, depression self-report assessments, and psychoeducational content. The primary outcome was the feasibility of engagement, which was based on the number and type of participant-generated actions that were completed in the app. The primary clinical end point was a comparison of the baseline and final assessments of the Patient Health Questionnaire-9. RESULTS: Of the 245 individuals who were referred by their primary care provider for behavioral health services, 89 (36.3%) consented to app-augmented behavioral health care. Only 12% (11/89) never engaged with the app during the study period. Across all participants, we observed a median engagement of 7 (IQR 12; mean 10.4; range 0-130) actions in the app (participants: n=78). The chat function was the most popular, followed by psychoeducational content and assessments. The subgroup analysis revealed no significant differences in app usage by age (P=.42) or sex (P=.84). The clinical improvement rate in our sample was 73% (32/44), although follow-up assessments were only available for 49% (44/89) of participants. CONCLUSIONS: Our preliminary findings indicate the moderate feasibility of using mHealth technology to augment behavioral health care in primary care settings. The results of this study are applicable to improving the design and implementation of mobile apps in collaborative care.
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BACKGROUND: The collaborative care model (CoCM) is a well-established system of behavioral health care in primary care settings. There is potential for digital and mobile technology to augment the CoCM to improve access, scalability, efficiency, and clinical outcomes. OBJECTIVE: This study aims to conduct a scoping review to synthesize the evidence available on digital and mobile health technology in collaborative care settings. METHODS: This review included cohort and experimental studies of digital and mobile technologies used to augment the CoCM. Studies examining primary care without collaborative care were excluded. A literature search was conducted using 4 electronic databases (MEDLINE, Embase, Web of Science, and Google Scholar). The search results were screened in 2 stages (title and abstract screening, followed by full-text review) by 2 reviewers. RESULTS: A total of 3982 nonduplicate reports were identified, of which 20 (0.5%) were included in the analysis. Most studies used a combination of novel technologies. The range of digital and mobile health technologies used included mobile apps, websites, web-based platforms, telephone-based interactive voice recordings, and mobile sensor data. None of the identified studies used social media or wearable devices. Studies that measured patient and provider satisfaction reported positive results, although some types of interventions increased provider workload, and engagement was variable. In studies where clinical outcomes were measured (7/20, 35%), there were no differences between groups, or the differences were modest. CONCLUSIONS: The use of digital and mobile health technologies in CoCM is still limited. This study found that technology was most successful when it was integrated into the existing workflow without relying on patient or provider initiative. However, the effect of digital and mobile health on clinical outcomes in CoCM remains unclear and requires additional clinical trials.
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Recent research has explored computational tools to manage workplace stress via personal sensing, a measurement paradigm in which behavioral data streams are collected from technologies including smartphones, wearables, and personal computers. As these tools develop, they invite inquiry into how they can be appropriately implemented towards improving workers' well-being. In this study, we explored this proposition through formative interviews followed by a design provocation centered around measuring burnout in a U.S. resident physician program. Residents and their supervising attending physicians were presented with medium-fidelity mockups of a dashboard providing behavioral data on residents' sleep, activity and time working; self-reported data on residents' levels of burnout; and a free text box where residents could further contextualize their well-being. Our findings uncover tensions around how best to measure workplace well-being, who within a workplace is accountable for worker stress, and how the introduction of such tools remakes the boundaries of appropriate information flows between worker and workplace. We conclude by charting future work confronting these tensions, to ensure personal sensing is leveraged to truly improve worker well-being.
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BACKGROUND: Little is known about the internet search activity of people with suicidal thoughts and behaviors (STBs). This data source has the potential to inform both clinical and public health efforts, such as suicide risk assessment and prevention. OBJECTIVE: We aimed to evaluate the internet search activity of suicidal young people to find evidence of suicidal ideation and behavioral health-related content. METHODS: Individuals aged between 15 and 30 years (N=43) with mood disorders who were hospitalized for STBs provided access to their internet search history. Searches that were conducted in the 3-month period prior to hospitalization were extracted and manually evaluated for search themes related to suicide and behavioral health. RESULTS: A majority (27/43, 63%) of participants conducted suicide-related searches. Participants searched for information that exactly matched their planned or chosen method of attempting suicide in 21% (9/43) of cases. Suicide-related search queries also included unusual suicide methods and references to suicide in popular culture. A majority of participants (33/43, 77%) had queries related to help-seeking themes, including how to find inpatient and outpatient behavioral health care. Queries related to mood and anxiety symptoms were found among 44% (19/43) of participants and included references to panic disorder, the inability to focus, feelings of loneliness, and despair. Queries related to substance use were found among 44% (19/43) of participants. Queries related to traumatic experiences were present among 33% (14/43) of participants. Few participants conducted searches for crisis hotlines (n=3). CONCLUSIONS: Individuals search the internet for information related to suicide prior to hospitalization for STBs. The improved understanding of the search activity of suicidal people could inform outreach, assessment, and intervention strategies for people at risk. Access to search data may also benefit the ongoing care of suicidal patients.
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BACKGROUND: Kaposi's sarcoma (KS) is one of the most common HIV-associated malignancies in sub-Saharan Africa. Worldwide, the availability of antiretroviral therapy (ART) has improved KS survival. In resource-rich settings, survival has also benefited from chemotherapy, which is widely available. Little is known, however, about the epidemiology of chemotherapy use for HIV-associated KS in resource-limited regions such as sub-Saharan Africa. METHODS: We identified all patients newly diagnosed with HIV-related KS from 2009 to 2012 in the 26-clinic AMPATH network, a large community-based care network in Kenya. We ascertained disease severity at diagnosis, frequency of initiation of chemotherapy, and distribution of chemotherapeutic regimens used. Indications for chemotherapy included AIDS Clinical Trial Group T1 stage and/or "severe" disease defined by WHO KS treatment guidelines. RESULTS: Of 674 patients diagnosed with KS, charts were available for 588; 61% were men, median age was 35 years, and median CD4 at KS diagnosis was 185 cells/µl. At time of diagnosis, 58% had at least one chemotherapy indication, and 22% had more than one indication. For patients with a chemotherapy indication, cumulative incidence of chemotherapy initiation (with death as a competing event) was 37% by 1 month and 56% by 1 year. Median time from diagnosis to chemotherapy initiation was 25 days (IQR 1-50 days). In multivariable regression, patients with > 3 chemotherapy indications at time of diagnosis had a 2.30 (95% CI 1.46-3.60) increased risk of rapid chemotherapy initiation (within 30 days of diagnosis) compared to those with only one chemotherapy indication (p < 0.001). Initial regimens were bleomycin-vincristine (78%), adriamycin-bleomycin-vincristine (11%), etoposide (7%), and gemcitabine (4%). CONCLUSIONS: A substantial fraction of patients with KS in East Africa are diagnosed at advanced disease stage. For patients with chemotherapy indications, nearly half did not receive chemotherapy by one year. Liposomal anthracyclines, often used in resource-rich settings, were not first line. These findings emphasize challenges in East Africa cancer care, and highlight the need for further advocacy for improved access to higher quality chemotherapy in this setting.