Browsing by Author "Lentz, Trevor A"
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Item Open Access Assessment of Common Comorbidity Phenotypes Among Older Adults With Knee Osteoarthritis to Inform Integrated Care Models.(Mayo Clinic proceedings. Innovations, quality & outcomes, 2021-04) Lentz, Trevor A; Hellkamp, Anne S; Bhavsar, Nrupen A; Goode, Adam P; Manhapra, Ajay; George, Steven ZObjective
To establish the frequency of concordant, discordant, and clinically dominant comorbidities among Medicare beneficiaries with knee osteoarthritis (KOA) and to identify common concordant condition subgroups.Participants and methods
We used a 5% representative sample of Medicare claims data to identify beneficiaries who received a diagnosis of KOA between January 1, 2012, and September 30, 2015, and matched control group without an osteoarthritis (OA) diagnosis. Frequency of 34 comorbid conditions was categorized as concordant, discordant, or clinically dominant among those with KOA and a matched sample without OA. Comorbid condition phenotypes were characterized by concordant conditions and derived using latent class analysis among those with KOA.Results
The study sample included 203,361 beneficiaries with KOA and 203,361 non-OA controls. The largest difference in frequency between the two cohorts was for co-occurring musculoskeletal conditions (23.7% absolute difference), chronic pain syndromes (6.5%), and rheumatic diseases (4.5%), all with a higher frequency among those with knee OA. Phenotypes were identified as low comorbidity (53% of cohort with classification), hypothyroid/osteoporosis (27%), vascular disease (10%), and high medical and psychological comorbidity (10%).Conclusions
Approximately 47% of Medicare beneficiaries with KOA in this sample had a phenotype characterized by one or more concordant conditions, suggesting that existing clinical pathways that rely on single or dominant providers might be insufficient for a large proportion of older adults with KOA. These findings could guide development of integrated KOA-comorbidity care pathways that are responsive to emerging priorities for personalized, value-based health care.Item Open Access Derivation of a Risk Assessment Tool for Prediction of Long-Term Pain Intensity Reduction After Physical Therapy.(Journal of pain research, 2021-01) Horn, Maggie E; George, Steven Z; Li, Cai; Luo, Sheng; Lentz, Trevor ARationale
Risk assessment tools can improve clinical decision-making for individuals with musculoskeletal pain, but do not currently exist for predicting reduction of pain intensity as an outcome from physical therapy.Aims and objective
The objective of this study was to develop a tool that predicts failure to achieve a 50% pain intensity reduction by 1) determining the appropriate statistical model to inform the tool and 2) select the model that considers the tradeoff between clinical feasibility and statistical accuracy.Methods
This was a retrospective, secondary data analysis of the Optimal Screening for Prediction of Referral and Outcome (OSPRO) cohort. Two hundred and seventy-nine individuals seeking physical therapy for neck, shoulder, back, or knee pain who completed 12-month follow-up were included. Two modeling approaches were taken: a longitudinal model included demographics, presence of previous episodes of pain, and regions of pain in addition to baseline and change in OSPRO Yellow Flag scores to 12 months; two comparison models included the same predictors but assessed only baseline and early change (4 weeks) scores. The primary outcome was failure to achieve a 50% reduction in pain intensity score at 12 months. We compared the area under the curve (AUC) to assess the performance of each candidate model and to determine which to inform the Personalized Pain Prediction (P3) risk assessment tool.Results
The baseline only and early change models demonstrated lower accuracy (AUC=0.68 and 0.71, respectively) than the longitudinal model (0.79) but were within an acceptable predictive range. Therefore, both baseline and early change models were used to inform the P3 risk assessment tool.Conclusion
The P3 tool provides physical therapists with a data-driven approach to identify patients who may be at risk for not achieving improvements in pain intensity following physical therapy.Item Open Access Framework for improving outcome prediction for acute to chronic low back pain transitions.(Pain reports, 2020-03-04) George, Steven Z; Lentz, Trevor A; Beneciuk, Jason M; Bhavsar, Nrupen A; Mundt, Jennifer M; Boissoneault, JeffClinical practice guidelines and the Federal Pain Research Strategy (United States) have recently highlighted research priorities to lessen the public health impact of low back pain (LBP). It may be necessary to improve existing predictive approaches to meet these research priorities for the transition from acute to chronic LBP. In this article, we first present a mapping review of previous studies investigating this transition and, from the characterization of the mapping review, present a predictive framework that accounts for limitations in the identified studies. Potential advantages of implementing this predictive framework are further considered. These advantages include (1) leveraging routinely collected health care data to improve prediction of the development of chronic LBP and (2) facilitating use of advanced analytical approaches that may improve prediction accuracy. Furthermore, successful implementation of this predictive framework in the electronic health record would allow for widespread testing of accuracy resulting in validated clinical decision aids for predicting chronic LBP development.Item Open Access Improving Veteran Access to Integrated Management of Back Pain (AIM-Back): Protocol for an Embedded Pragmatic Cluster-Randomized Trial.(Pain medicine (Malden, Mass.), 2020-12) George, Steven Z; Coffman, Cynthia J; Allen, Kelli D; Lentz, Trevor A; Choate, Ashley; Goode, Adam P; Simon, Corey B; Grubber, Janet M; King, Heather; Cook, Chad E; Keefe, Francis J; Ballengee, Lindsay A; Naylor, Jennifer; Brothers, Joseph Leo; Stanwyck, Catherine; Alkon, Aviel; Hastings, Susan NBackground
Coordinated efforts between the National Institutes of Health, the Department of Defense, and the Department of Veterans Affairs have built the capacity for large-scale clinical research investigating the effectiveness of nonpharmacologic pain treatments. This is an encouraging development; however, what constitutes best practice for nonpharmacologic management of low back pain (LBP) is largely unknown.Design
The Improving Veteran Access to Integrated Management of Back Pain (AIM-Back) trial is an embedded pragmatic cluster-randomized trial that will examine the effectiveness of two different care pathways for LBP. Sixteen primary care clinics will be randomized 1:1 to receive training in delivery of 1) an integrated sequenced-care pathway or 2) a coordinated pain navigator pathway. Primary outcomes are pain interference and physical function (Patient-Reported Outcomes Measurement Information System Short Form [PROMIS-SF]) collected in the electronic health record at 3 months (n=1,680). A subset of veteran participants (n=848) have consented to complete additional surveys at baseline and at 3, 6, and 12 months for supplementary pain and other measures.Summary
AIM-Back care pathways will be tested for effectiveness, and treatment heterogeneity will be investigated to identify which veterans may respond best to a given pathway. Health care utilization patterns (including opioid use) will also be compared between care pathways. Therefore, the AIM-Back trial will provide important information that can inform the future delivery of nonpharmacologic treatment of LBP.Item Open Access Interventions for the Management of Acute and Chronic Low Back Pain: Revision 2021.(The Journal of orthopaedic and sports physical therapy, 2021-11) George, Steven Z; Fritz, Julie M; Silfies, Sheri P; Schneider, Michael J; Beneciuk, Jason M; Lentz, Trevor A; Gilliam, John R; Hendren, Stephanie; Norman, Katherine SLow back pain (LBP) remains a musculoskeletal condition with an adverse societal impact. Globally, LBP is highly prevalent and a leading cause of disability. This is an update to the 2012 Academy of Orthopaedic Physical Therapy (AOPT), formerly the Orthopaedic Section of the American Physical Therapy Association (APTA), clinical practice guideline (CPG) for LBP. The overall objective of this update was to provide recommendations on interventions delivered by physical therapists or studied in care settings that included physical therapy providers. It also focused on synthesizing new evidence, with the purpose of making recommendations for specific nonpharmacologic treatments. J Orthop Sports Phys Ther 2021;51(11):CPG1-CPG60. doi:10.2519/jospt.2021.0304.Item Open Access Longitudinal Monitoring of Pain Associated Distress with the Optimal Screening for Prediction of Referral and Outcome Yellow Flag (OSPRO-YF) Tool: Predicting Reduction Pain Intensity and Disability.(Archives of physical medicine and rehabilitation, 2020-06-26) George, Steven Z; Li, Cai; Luo, Sheng; Horn, Maggie E; Lentz, Trevor AOBJECTIVE:To investigate the Optimal Screening for Prediction of Referral and Outcome Yellow Flag (OSPRO-YF) tool for longitudinal monitoring of pain associated distress with the goal of improving prediction of 50% reduction in pain intensity and disability outcomes. DESIGN:Cohort study with 12-month follow-up after initial care episode SETTING: Ambulatory care, participants seeking care from out-patient physical therapy clinics PARTICIPANTS: Participants were seeking care for primary complaint of neck, low back, knee or shoulder pain. This secondary analysis included 440 subjects (62.5% female; mean age 45.1± 17) at baseline with n=279 (63.4%) providing follow-up data at 12 months. INTERVENTIONS:Not applicable MAIN OUTCOME MEASURES: 50% reduction (baseline to 12-month follow-up) in pain intensity and self-reported disability RESULTS: Trends for prediction accuracy were similar for all versions of the OSPRO-YF. For predicting 50% reduction in pain intensity, model fit met the statistical criterion for improvement (i.e., p < 0.05) with each additional time point added from baseline. Model discrimination improved statistically when the 6-month to 12-month change was added to the model (Area Under the Curve = 0.849, p = 0.003). For predicting 50% reduction in disability, there was no evidence of improvement in model fit or discrimination from baseline with the addition of 4-week, 6-month, or 12-month changes (p's > 0.05). CONCLUSIONS:These results suggested that longitudinal monitoring improved prediction accuracy for reduction in pain intensity, but not for disability reduction. Differences in OSPRO-YF item sets (10 vs. 17 items) or scoring methods (simple summary score vs. yellow flag count) did not impact predictive accuracy for pain intensity, providing flexibility for implementing this tool in practice settings.Item Open Access Overcoming Barriers to the Implementation of Integrated Musculoskeletal Pain Management Programs: A Multi-Stakeholder Qualitative Study.(The journal of pain, 2023-05) Lentz, Trevor A; Gonzalez-Smith, Jonathan; Huber, Katie; Goertz, Christine; Bleser, William K; Saunders, RobertIntegrated pain management (IPM) programs can help to reduce the substantial population health burden of musculoskeletal pain, but are poorly implemented. Lessons learned from existing programs can inform efforts to expand IPM implementation. This qualitative study describes how health care systems, payers, providers, health policy researchers, and other stakeholders are overcoming barriers to developing and sustaining IPM programs in real-world settings. Primary data were collected February 2020 through September 2021 from a multi-sector expert panel of 25 stakeholders, 53 expert interviews representing 30 distinct IPM programs across the United States, and 4 original case studies of exemplar IPM programs. We use a consensual team-based approach to systematically analyze qualitative findings. We identified 4 major themes around challenges and potential solutions for implementing IPM programs: navigating coverage, payment, and reimbursement; enacting organizational change; making a business case to stakeholders; and overcoming regulatory hurdles. Strategies to address payment challenges included use of group visits, linked visits between billable and nonbillable providers, and development of value-based payment models. Organizational change strategies included engagement of clinical and administrative champions and co-location of services. Business case strategies involved demonstrating the ability to initially break even and potential to reduce downstream costs, while improving nonfinancial outcomes like patient satisfaction and provider burnout. Regulatory hurdles were overcome with innovative credentialing methods by leveraging available waivers and managed care contracting to expand access to IPM services. Lessons from existing programs provide direction on to grow and support such IPM delivery models across a variety of settings. PERSPECTIVE: Integrated pain management (IPM) programs face numerous implementation challenges related to payment, organizational change, care coordination, and regulatory requirements. Drawing on real-world experiences of existing programs and from diverse IPM stakeholders, we outline actionable strategies that health care systems, providers, and payers can use to expand implementation of these programs.Item Open Access Partner engagement for planning and development of non-pharmacological care pathways in the AIM-Back trial.(Clinical trials (London, England), 2023-06) Ballengee, Lindsay A; King, Heather A; Simon, Corey; Lentz, Trevor A; Allen, Kelli D; Stanwyck, Catherine; Gladney, Micaela; George, Steven Z; Hastings, S NicoleBackground/aims
Embedded pragmatic clinical trials are increasingly recommended for non-pharmacological pain care research due to their focus on examining intervention effectiveness within real-world settings. Engagement with patients, health care providers, and other partners is essential, yet there is limited guidance for how to use engagement to meaningfully inform the design of interventions to be tested in pain-related pragmatic clinical trials. This manuscript aims to describe the process and impacts of partner input on the design of two interventions (care pathways) for low back pain currently being tested in an embedded pragmatic trial in the Veterans Affairs health care system.Methods
Sequential cohort design for intervention development was followed. Engagement activities were conducted with 25 participants between November 2017 and June 2018. Participants included representatives from multiple groups: clinicians, administrative leadership, patients, and caregivers.Results
Partner feedback led to several changes in each of the care pathways to improve patient experience and usability. Major changes to the sequenced care pathway included transitioning from telephone-based delivery to a flexible telehealth model, increased specificity about pain modulation activities, and reduction of physical therapy visits. Major changes to the pain navigator pathway included transitioning from a traditional stepped care model to one that offers care in a feedback loop, increased flexibility regarding pain navigator provider type, and increased specificity for patient discharge criteria. Centering patient experience emerged as a key consideration from all partner groups.Conclusion
Diverse input is important to consider before implementing new interventions in embedded pragmatic trials. Partner engagement can increase acceptability of new care pathways to patients and providers and enhance uptake of effective interventions by health systems.Trial registration
NCT#04411420. Registered on 2 June 2020.Item Open Access Venous Thromboembolism Prophylaxis and Hormonal Contraceptive Management Practice Patterns in the Perioperative Period for Anterior Cruciate Ligament Reconstruction.(Arthroscopy, sports medicine, and rehabilitation, 2022-04) Christian, Robert A; Lander, Sarah T; Bonazza, Nicholas A; Reinke, Emily K; Lentz, Trevor A; Dodds, Julie A; Mulcahey, Mary K; Ford, Anne C; Wittstein, Jocelyn RPurpose
To evaluate the venous thromboembolism (VTE) prophylaxis practices of surgeons performing anterior cruciate ligament reconstruction (ACLR) in female patients using hormonal contraceptives.Methods
Our research team designed an investigational survey using branching logic that was made available to the AANA membership. The survey was designed to identify clinical decision making regarding VTE prophylaxis after ACLR in patients without risk factors for VTE, the counseling of patients about VTE risk associated with hormonal contraceptives, and the use of VTE prophylaxis after ACLR in patients taking hormonal contraceptives.Results
Ninety-four respondents completed the survey. Eighty-nine respondents identified their gender (63% male and 37% female respondents). Respondents reported performing the following number of ACLRs annually: more than 50 (40%), 30 to 50 (29%), 15 to 30 (29%), and fewer than 15 (2%). Of the respondents, 62 (67%) reported that VTE developed after ACLR in their patients (male patients only, 32%; female patients only, 24%; and both male and female patients, 34%). Sixty-seven percent used chemoprophylaxis after ACLR. Surgeons who asked about hormonal contraceptive use were more likely to be women (P = .01; odds ratio [OR], 4.2). Surgeons who changed their VTE prophylaxis plan as a result of asking about hormonal contraceptive use were more likely to be women (P = .02; OR, 2.8). Surgeons who asked about hormonal contraceptive use were more likely to have female patients with VTE after ACLR (P = .03; OR, 2.9). Surgeons who changed their VTE prophylaxis plan as a result of asking about hormonal contraceptive use were more likely to have female patients with VTE after ACLR (P = .001; OR, 4.6).Conclusions
There is no standard of care for VTE prophylaxis after ACLR. A surgeon's own gender and prior clinical experience with VTE after ACLR may influence his or her likelihood to consider a patient's hormonal contraceptive use regarding VTE risk after ACLR.Clinical relevance
The use of hormonal contraception is a risk factor for VTE in female patients undergoing ACLR. It is important to identify current practice patterns and the need for a standard of care.