Browsing by Author "Marshall, Stephen W"

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    A Randomized Controlled Trial Investigating the Feasibility and Adherence to an Aerobic Training Program in Healthy Individuals.
    (Journal of sport rehabilitation, 2019-09) Teel, Elizabeth F; Marshall, Stephen W; Appelbaum, L Gregory; Battaglini, Claudio L; Carneiro, Kevin A; Guskiewicz, Kevin M; Register-Mihalik, Johna K; Mihalik, Jason P
    CONTEXT:Concussion management is moving from passive rest strategies to active interventions, including aerobic exercise therapy. Little information is available regarding the feasibility and adherence of these programs. OBJECTIVES:To determine whether an aerobic exercise training program intended for rehabilitation in people with concussion is feasible. Healthy, nonconcussed subjects were studied in this phase 1 trial. DESIGN:Phase 1 parallel-group, randomized controlled trial in a sample of healthy (nonconcussed), recreationally active university students. SETTING:Laboratory. PATIENTS:40 healthy university students. METHODS:Participants were equally randomized to acute concussion therapy intervention (ACTIVE) training or nontraining groups. All participants completed maximal cardiopulmonary exercise tests on a stationary cycle ergometer at 2 test sessions approximately 14 days apart. During this 2-week study period, ACTIVE training participants completed six 30-minute cycling sessions, progressing from 60% to 80% of the participant's individualized maximal oxygen consumption. A subset of participants (NACTIVE = 12, Nnontraining = 11) wore physical activity monitors throughout the 2-week study period. MAIN OUTCOMES MEASURES:Study protocol and randomization effectiveness, exercise safety and adherence, and progressive intensity of the ACTIVE training procedures. RESULTS:No adverse events occurred during any exercise sessions. Twelve ACTIVE training participants (60%) completed all training sessions, and every participant completed at least 4 sessions. Heart rate increased throughout the training period (P < .001), but symptom changes and training adherence remained stable despite the progressively increasing workload. ACTIVE training participants completed approximately 30 additional minutes of physical activity on training sessions days, although that was not statistically significant (P = .20). CONCLUSIONS:University-aged students were adherent to the ACTIVE training protocol. Future research should investigate the safety and feasibility of aerobic training programs in acutely concussed individuals to determine their appropriateness as a clinical rehabilitation strategy.
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    Development and validation of an electronic health records-based opioid use disorder algorithm by expert clinical adjudication among patients with prescribed opioids.
    (Pharmacoepidemiology and drug safety, 2023-05) Ranapurwala, Shabbar I; Alam, Ishrat Z; Pence, Brian W; Carey, Timothy S; Christensen, Sean; Clark, Marshall; Chelminski, Paul R; Wu, Li-Tzy; Greenblatt, Lawrence H; Korte, Jeffrey E; Wolfson, Mark; Douglas, Heather E; Bowlby, Lynn A; Capata, Michael; Marshall, Stephen W

    Background

    In the US, over 200 lives are lost from opioid overdoses each day. Accurate and prompt diagnosis of opioid use disorders (OUD) may help prevent overdose deaths. However, international classification of disease (ICD) codes for OUD are known to underestimate prevalence, and their specificity and sensitivity are unknown. We developed and validated algorithms to identify OUD in electronic health records (EHR) and examined the validity of OUD ICD codes.

    Methods

    Through four iterations, we developed EHR-based OUD identification algorithms among patients who were prescribed opioids from 2014 to 2017. The algorithms and OUD ICD codes were validated against 169 independent "gold standard" EHR chart reviews conducted by an expert adjudication panel across four healthcare systems. After using 2014-2020 EHR for validating iteration 1, the experts were advised to use 2014-2017 EHR thereafter.

    Results

    Of the 169 EHR charts, 81 (48%) were reviewed by more than one expert and exhibited 85% expert agreement. The experts identified 54 OUD cases. The experts endorsed all 11 OUD criteria from the Diagnostic and Statistical Manual of Mental Disorders-5, including craving (72%), tolerance (65%), withdrawal (56%), and recurrent use in physically hazardous conditions (50%). The OUD ICD codes had 10% sensitivity and 99% specificity, underscoring large underestimation. In comparison our algorithm identified OUD with 23% sensitivity and 98% specificity.

    Conclusions and relevance

    This is the first study to estimate the validity of OUD ICD codes and develop validated EHR-based OUD identification algorithms. This work will inform future research on early intervention and prevention of OUD.
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    Implementation of mandatory opioid prescribing limits in North Carolina: healthcare administrator and prescriber perspectives.
    (BMC health services research, 2021-11-03) Blackburn, Natalie A; Joniak-Grant, Elizabeth; Nocera, Maryalice; Dorris, Samantha Wooten; Dasgupta, Nabarun; Chelminski, Paul R; Carey, Timothy S; Wu, Li-Tzy; Edwards, David A; Marshall, Stephen W; Ranapurwala, Shabbar I

    Background

    Recent increases in state laws to reduce opioid prescribing have demonstrated a need to understand how they are interpreted and implemented in healthcare systems. The purpose of this study was to explore the systems, strategies, and resources that hospital administrators and prescribers used to implement the 2017 North Carolina Strengthen Opioid Prevention (STOP) Act opioid prescribing limits, which limited initial prescriptions to a five (for acute) or seven (for post-surgical) days' supply.

    Methods

    We interviewed 14 hospital administrators and 38 prescribers with degrees in medicine, nursing, pharmacy, business administration and public health working across North Carolina. Interview guides, informed by the Consolidated Framework for Implementation Research, explored barriers and facilitators to implementation. Interview topics included communication, resources, and hospital system support. Interviews were recorded and transcribed, then analyzed using flexible coding, integrating inductive and deductive coding, to inform analytic code development and identify themes.

    Results

    We identified three main themes around implementation of STOP act mandated prescribing limits: organizational communication, prescriber education, and changes in the electronic medical record (EMR) systems. Administrators reflected on implementation in the context of raising awareness and providing reminders to facilitate changes in prescriber behavior, operationalized through email and in-person communications as well as dedicated resources to EMR changes. Prescribers noted administrative communications about prescribing limits often focused on legality, suggesting a directive of the organization's policy rather than a passive reminder. Prescribers expressed a desire for more spaces to have their questions answered and resources for patient communications. While hospital administrators viewed compliance with the law as a priority, prescribers reflected on concerns for adequately managing their patients' pain and limited time for clinical care.

    Conclusions

    Hospital administrators and prescribers approached implementation of the STOP act prescribing limits with different mindsets. While administrators were focused on policy compliance, prescribers were focused on their patients' needs. Strategies to implement the mandate then had to balance patient needs with policy compliance. As states continue to legislate to prevent opioid overdose deaths, understanding how laws are implemented by healthcare systems and prescribers will improve their effectiveness through tailoring and maximizing available resources.
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    Randomized Controlled Trial Evaluating Aerobic Training and Common Sport-Related Concussion Outcomes in Healthy Participants.
    (Journal of athletic training, 2018-12-18) Teel, Elizabeth F; Register-Mihalik, Johna K; Appelbaum, Lawrence Gregory; Battaglini, Claudio L; Carneiro, Kevin A; Guskiewicz, Kevin M; Marshall, Stephen W; Mihalik, Jason P
    CONTEXT:Aerobic exercise interventions are increasingly being prescribed for concussion rehabilitation, but whether aerobic training protocols influence clinical concussion diagnosis and management assessments is unknown. OBJECTIVE:To investigate the effects of a brief aerobic exercise intervention on clinical concussion outcomes in healthy, active participants. DESIGN:Randomized controlled clinical trial. SETTING:Laboratory. PATIENTS OR OTHER PARTICIPANTS:Healthy (uninjured) participants (n = 40) who exercised ≥3 times/week. INTERVENTION(S):Participants were randomized into the acute concussion therapy intervention (ACTIVE) training or nontraining group. All participants completed symptom, cognitive, balance, and vision assessments during 2 test sessions approximately 14 days apart. Participants randomized to ACTIVE training completed six 30-minute exercise sessions that progressed from 60% to 80% of individualized maximal oxygen consumption (V˙o2max) across test sessions, while the nontraining group received no intervention. MAIN OUTCOME MEASURE(S):The CNS Vital Signs standardized scores, Vestibular/Ocular Motor Screening near-point convergence distance (cm), and Graded Symptom Checklist, Balance Error Scoring System, and Standardized Assessment of Concussion total scores. RESULTS:An interaction effect was found for total symptom score ( P = .01); the intervention group had improved symptom scores between sessions (session 1: 5.1 ± 5.8; session 2: 1.9 ± 3.6). Cognitive flexibility, executive functioning, reasoning, and total symptom score outcomes were better but composite memory, verbal memory, and near-point convergence distance scores were worse at the second session (all P values < .05). However, few changes exceeded the 80% reliable change indices calculated for this study, and effect sizes were generally small to negligible. CONCLUSIONS:A brief aerobic training protocol had few meaningful effects on clinical concussion assessment in healthy participants, suggesting that current concussion-diagnostic and -assessment tools remain clinically stable in response to aerobic exercise training. This provides normative data for future researchers, who should further evaluate the effect of ACTIVE training on clinical outcomes among concussed populations. TRIAL REGISTRATION NUMBER:ClinicalTrials.gov : NCT02872480.