RESUMEN
OBJECTIVES: To determine the health impacts of three future scenarios of travel behavior by mode for the City of Los Angeles, California, and to provide specific recommendations for how to conduct health impact assessments of local transportation plans on a more routine basis. METHODS: We used the Integrated Transportation and Health Impact Model to assess the health impacts of the Los Angeles Mobility Plan 2035 by using environmental impact report data on miles traveled by mode under alternative implementation scenarios as inputs. The Integrated Transportation and Health Impact Model links region-wide changes in travel behavior to population exposures to physical activity, air pollution, and traffic collisions and associated health outcomes and costs. RESULTS: The largest impacts were on cardiovascular disease through increases in physical activity. Reductions in air pollution-related illnesses were more modest. Traffic injuries and deaths increased across all scenarios but were greatly reduced through targeted roadway safety enhancements accounted for outside the model. CONCLUSIONS: By establishing miles travelled as the metric for transportation impacts of statewide and regional plans, states can leverage existing data sources to more routinely consider health impacts as part of environmental impact reports. While not insurmountable, challenges remain regarding the incorporation of land use and roadway safety strategies into health impact estimates.
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Ciclismo/estadística & datos numéricos , Planificación Ambiental/estadística & datos numéricos , Ejercicio Físico , Evaluación del Impacto en la Salud , Transportes/estadística & datos numéricos , Adulto , Anciano , Anciano de 80 o más Años , Ciudades/estadística & datos numéricos , Femenino , Humanos , Los Angeles , Masculino , Persona de Mediana EdadRESUMEN
BACKGROUND: Comorbid depression is a significant challenge for safety-net primary care systems. Team-based collaborative depression care is effective, but complex system factors in safety-net organizations impede adoption and result in persistent disparities in outcomes. Diabetes-Depression Care-management Adoption Trial (DCAT) evaluated whether depression care could be significantly improved by harnessing information and communication technologies to automate routine screening and monitoring of patient symptoms and treatment adherence and allow timely communication with providers. OBJECTIVE: The aim of this study was to compare 6-month outcomes of a technology-facilitated care model with a usual care model and a supported care model that involved team-based collaborative depression care for safety-net primary care adult patients with type 2 diabetes. METHODS: DCAT is a translational study in collaboration with Los Angeles County Department of Health Services, the second largest safety-net care system in the United States. A comparative effectiveness study with quasi-experimental design was conducted in three groups of adult patients with type 2 diabetes to compare three delivery models: usual care, supported care, and technology-facilitated care. Six-month outcomes included depression and diabetes care measures and patient-reported outcomes. Comparative treatment effects were estimated by linear or logistic regression models that used generalized propensity scores to adjust for sampling bias inherent in the nonrandomized design. RESULTS: DCAT enrolled 1406 patients (484 in usual care, 480 in supported care, and 442 in technology-facilitated care), most of whom were Hispanic or Latino and female. Compared with usual care, both the supported care and technology-facilitated care groups were associated with significant reduction in depressive symptoms measured by scores on the 9-item Patient Health Questionnaire (least squares estimate, LSE: usual care=6.35, supported care=5.05, technology-facilitated care=5.16; P value: supported care vs usual care=.02, technology-facilitated care vs usual care=.02); decreased prevalence of major depression (odds ratio, OR: supported care vs usual care=0.45, technology-facilitated care vs usual care=0.33; P value: supported care vs usual care=.02, technology-facilitated care vs usual care=.007); and reduced functional disability as measured by Sheehan Disability Scale scores (LSE: usual care=3.21, supported care=2.61, technology-facilitated care=2.59; P value: supported care vs usual care=.04, technology-facilitated care vs usual care=.03). Technology-facilitated care was significantly associated with depression remission (technology-facilitated care vs usual care: OR=2.98, P=.04); increased satisfaction with care for emotional problems among depressed patients (LSE: usual care=3.20, technology-facilitated care=3.70; P=.05); reduced total cholesterol level (LSE: usual care=176.40, technology-facilitated care=160.46; P=.01); improved satisfaction with diabetes care (LSE: usual care=4.01, technology-facilitated care=4.20; P=.05); and increased odds of taking an glycated hemoglobin test (technology-facilitated care vs usual care: OR=3.40, P<.001). CONCLUSIONS: Both the technology-facilitated care and supported care delivery models showed potential to improve 6-month depression and functional disability outcomes. The technology-facilitated care model has a greater likelihood to improve depression remission, patient satisfaction, and diabetes care quality.
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Depresión/terapia , Diabetes Mellitus Tipo 2/psicología , Atención Primaria de Salud/organización & administración , Comorbilidad , Depresión/patología , Diabetes Mellitus Tipo 2/epidemiología , Diabetes Mellitus Tipo 2/patología , Diabetes Mellitus Tipo 2/terapia , Femenino , Humanos , Masculino , Medición de Resultados Informados por el Paciente , Calidad de la Atención de Salud , Factores de TiempoRESUMEN
PURPOSE: We investigated dimensions of low-income minority patient engagement in the context of diabetes-depression care-management with automated telephone assessment (ATA) calls as a facilitator. METHODS: Mixed method analyses (including regression analyses and coding of interviews) were used to examine patient engagement with technology, assess its impact on health outcomes and satisfaction with care, and analyze barriers to engagement. Patient engagement was measured by analyzing patient's ATA call response rates. We then evaluated those results in the context of the outcomes of the broader clinical trial, which compared three study arms. RESULTS: Average completed call rate throughout the study is about 50 % and decreases after 6 months. The biggest barrier to patient engagement is timing. Patient engagement levels differ by baseline depression status and have no significant effect on health outcomes and satisfaction with care at 6, 12, and 18 months. However, from the preliminary clinical trial results, the arm in which the ATA system is implemented has higher satisfaction with depression care than the two control arms. Thus, it is more likely that technology positively affects satisfaction with depression care outcomes through provider engagement rather than patient engagement. CONCLUSIONS: The study's patient engagement results and identified barriers would be useful to aid the design and implementation of future automated screening and monitoring systems to optimize patient engagement. The results also suggest that implementing a technology-supported care-management might not result in outcome disparities among patients with different levels of patient engagement.
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Trastorno Depresivo/diagnóstico , Complicaciones de la Diabetes/psicología , Participación del Paciente , Calidad de Vida/psicología , Teléfono , Adulto , Anciano , Recolección de Datos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Grupos Minoritarios/psicología , Pobreza/psicología , AutocuidadoRESUMEN
INTRODUCTION: The prevalence of comorbid diabetes and depression is high, especially in low-income Hispanic or Latino patients. The complex mix of factors in safety-net care systems impedes the adoption of evidence-based collaborative depression care and results in persistent disparities in depression outcomes. The Diabetes-Depression Care-Management Adoption Trial examined whether the collaborative depression care model is an effective approach in safety-net clinics to improve clinical care outcomes of depression and diabetes. METHODS: A sample of 964 patients with diabetes from 5 safety-net clinics were enrolled in a quasi-experimental study that included 2 arms: usual care, in which primary medical providers and staff translated and adopted evidence-based depression care; and supportive care, in which providers of a disease management program delivered protocol-driven depression care. Because the study design established individual treatment centers as separate arms, we calculated propensity scores that interpreted the probability of treatment assignment conditional on observed baseline characteristics. Primary outcomes were 5 depression care outcomes and 7 diabetes care measures. Regression models with propensity score covariate adjustment were applied to analyze 6-month outcomes. RESULTS: Compared with usual care, supportive care significantly decreased Patient Health Questionnaire-9 scores, reduced the number of patients with moderate or severe depression, improved depression remission, increased satisfaction in care for patients with emotional problems, and significantly reduced functional impairment. CONCLUSION: Implementing collaborative depression care in a diabetes disease management program is a scalable approach to improve depression outcomes and patient care satisfaction among patients with diabetes in a safety-net care system.
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Trastorno Depresivo/terapia , Diabetes Mellitus/terapia , Disparidades en Atención de Salud , Hispánicos o Latinos/psicología , Proveedores de Redes de Seguridad , Comorbilidad , Investigación sobre la Eficacia Comparativa , Prestación Integrada de Atención de Salud , Trastorno Depresivo/epidemiología , Diabetes Mellitus/epidemiología , Práctica Clínica Basada en la Evidencia , Femenino , Hispánicos o Latinos/estadística & datos numéricos , Humanos , América Latina/etnología , Modelos Lineales , Los Angeles , Masculino , Persona de Mediana Edad , Manejo de Atención al Paciente , Grupo de Atención al Paciente , Sistema de Registros , Investigación Biomédica Traslacional , Resultado del TratamientoRESUMEN
Depression is a significant challenge for ambulatory care because it worsens health status and outcomes, increases health care utilizations and costs, and elevates suicide risk. An automatic telephonic assessment (ATA) system that links with tasks and alerts to providers may improve quality of depression care and increase provider productivity. We used ATA system in a trial to assess and monitor depressive symptoms of 444 safety-net primary care patients with diabetes. We assessed system properties, evaluated preliminary clinical outcomes, and estimated cost savings. The ATA system is feasible, reliable, valid, safe, and likely cost-effective for depression screening and monitoring for low-income primary care population.
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Depresión/terapia , Diabetes Mellitus/psicología , Informática Médica , Atención Dirigida al Paciente , Atención Primaria de Salud , Atención Ambulatoria , Depresión/diagnóstico , Depresión/economía , Humanos , Los Angeles , Informática Médica/economía , Pobreza , Atención Primaria de Salud/organización & administración , TeléfonoRESUMEN
Health disparities in minority populations are well recognized. Hispanics and Latinos constitute the largest ethnic minority group in the United States; a significant proportion receives their care via a safety net. The prevalence of diabetes mellitus and comorbid depression is high among this group, but the uptake of evidence-based collaborative depression care management has been suboptimal. The study design and baseline characteristics of the enrolled sample in the Diabetes-Depression Care-management Adoption Trial (DCAT) establishes a quasi-experimental comparative effectiveness research clinical trial aimed at accelerating the adoption of collaborative depression care in safety net clinics. The study was conducted in collaboration with the Los Angeles County Department of Health Services at eight county-operated clinics. DCAT has enrolled 1406 low-income, predominantly Hispanic/Latino patients with diabetes to test a translational model of depression care management. This three-group study compares usual care with a collaborative care team support model and a technology-facilitated depression care model that provides automated telephonic depression screening and monitoring tailored to patient conditions and preferences. Call results are integrated into a diabetes disease management registry that delivers provider notifications, generates tasks, and issues critical alerts. All subjects receive comprehensive assessments at baseline, 6, 12, and 18 months by independent English-Spanish bilingual interviewers. Study outcomes include depression outcomes, treatment adherence, satisfaction, acceptance of assessment and monitoring technology, social and economic stress reduction, diabetes self-care management, health care utilization, and care management model cost and cost-effectiveness comparisons. DCAT's goal is to optimize depression screening, treatment, follow-up, outcomes, and cost savings to reduce health disparities.