Jamie L. Smith

Background: Heart failure self‐care can contribute to a high daily workload and treatment burden. The goal of this cohort study was to assess the characteristics and outcomes associated with burden of treatment (BoT). Methods: Surveys comprising validated instruments to measure BoT and other constructs were mailed to patients with heart failure in Southeastern Minnesota. Participants were divided into tertiles by BoT scores. Associations of clinical variables with BoT were examined using multinomial logistic regression. Associations of BoT with mortality and hospitalizations were examined using Cox proportional hazard regression and Andersen–Gill models, respectively. Results: A total of 609 participants (mean age 76.3 years, 60.3% men, 55.2% urban, 64.3% preserved ejection fraction) completed surveys. Higher BoT was associated with worse health status, more depressive symptoms, lower resilience, less social support, lower medication adherence, and worse health literacy. Mean±SD follow‐up was 14.4 (4.1) months. Estimated 1‐year mortality (8.3% [95% CI, 4.3%–12.1%], 11.0% [95% CI, 6.5%–15.2%], 16.0% [95% CI, 10.8%–21.0%]) and 1‐year mean cumulative hospitalizations (0.57 [95% CI, 0.45–0.72], 0.83 [95% CI, 0.66–1.05], 1.15 [95% CI, 0.93–1.42]) increased across patients reporting low, medium, and high BoT, respectively. Adjustment for health status eliminated any significant association of BoT with risks of death and hospitalization (adjusted hazard ratio [HR], 1.10 [95% CI, 0.58–2.07] and 1.09 [95% CI, 0.74–1.61], respectively, highest versus lowest BoT tertile). Conclusions: BoT in heart failure varies by clinical and psychosocial factors. Higher BoT identifies patients at increased risk of adverse health outcomes due to their worse health status. These findings can serve as a foundation for interventions to minimize workload and improve quality of life.

BACKGROUND: Validly measuring disease-specific health status is critical in patients with severe tricuspid regurgitation (TR) to quantify the benefit of different interventions. The Kansas City Cardiomyopathy Questionnaire (KCCQ) has been used to assess health status in patients with severe TR, but its content validity in this patient population is unknown, including whether additional questions are needed to supplement the KCCQ. METHODS: Twenty participants with symptomatic severe TR from 2 midwestern clinical sites were interviewed in 2023 using a semistructured guide. The interview guide addressed symptoms, physical and social functioning, and quality of life concepts of the KCCQ, as well as other potential TR symptoms not represented in the KCCQ. Interview transcripts were analyzed using inductive and deductive coding and content analysis, with additional participants recruited until thematic saturation occurred. RESULTS: Mean age of the participants was 80 (41–89), and 75% were female. Shortness of breath and fatigue were reported by virtually all participants (n=20 and n=19, respectively) and had a marked negative impact on their physical and social functioning and quality of life. Lower limb edema was also reported by 10 participants. Although these concepts are captured by the KCCQ, other symptoms were also reported, including appetite loss (n=8) and upper body edema (n=4), but did not seem to markedly affect participants’ function or quality of life. In addition, all participants who experienced these other symptoms reported symptoms that were already captured by the KCCQ. CONCLUSIONS: All participants experienced symptoms captured by the KCCQ, and these symptoms had a substantial impact on their physical and social functioning and quality of life. Although some participants reported additional symptoms not assessed by the KCCQ, their incorporation would only marginally improve content validity. Thus, the current KCCQ appears to be appropriate for capturing the disease-specific health status of patients with severe TR.

Background: COVID-19 worsened an already existing problem in substance use disorder (SUD) treatment. However, it helped transform the use of telehealth, which particularly benefits rural America. The lack of specialty addiction treatment in rural areas places the onus on primary care providers. Screening, brief intervention, and referral to treatment (SBIRT) is an evidenced-based strategy commonly used in primary care settings to target SUD outcomes and related behaviors. The integration of telehealth tools within the SBIRT pathway may better sustain the program in primary care. Building on Mayo Clinic’s experience with collaborative care management (CoCM) for mental health treatment, we built a digitally native, integrated, behavioral health CoCM platform using a novel mobile app and web-based provider platform called Senyo Health. Objective: This protocol describes a novel use of the SBIRT pathway using Senyo Health to complement existing CoCM integration within primary care to deliver SUD treatment to rural patients lacking other access. We hypothesize that this approach will improve SUD-related outcomes within rural primary care clinics. Methods: Senyo Health is a digital tool to facilitate the use of SBIRT in primary care. It contains a web-based platform for clinician and staff use and a patient-facing mobile phone app. The app includes 16 learning modules along with data collection tools and a chat function for communicating directly with a licensed drug counselor. Beta-testing is currently underway to examine opportunities to improve Senyo Health prior to the start of the trial. We describe the development of Senyo Health and its therapeutic content and data collection instruments. We also describe our evaluation strategy including our measurement plan to assess implementation through a process guided by Consolidated Framework for Implementation Research methods and effectiveness through a waitlist control trial. A randomized controlled trial will occur where 30 participants are randomly assigned to immediately start the Senyo intervention compared to a waitlist control group of 30 participants who will start the active intervention after a 12-week delay. Results: The Senyo Health app was launched in May 2023, and the most recent update was in August 2024. Our funding period began in September 2023 and will conclude in July 2027. This protocol defines a novel implementation strategy for leveraging a digitally native, clinical platform that enables the delivery of CoCM to target an SUD-specific patient population. Our trial will begin in June 2025. Conclusions: We present a theory of change and study design to assess the impact of a novel and patient-centered mobile app to support the SBIRT approach to SUD in primary care settings. Trial Registration: ClinicalTrials.gov NCT06743282; http://clinicaltrials.gov/ct2/show/NCT06743282 International Registered Report Identifier (IRRID): PRR1-10.2196/65693

Patient-provider communication through the patient portal has markedly increased in recent years. Some health care facilities implemented programs to enable providers to bill for responding to patient-initiated messages that require substantive medical decision making through an e-visit. To evaluate the effect of billing eligible patient-initiated portal messages as e-visits using a mixed-methods approach. Retrospective observational pre-post comparison and prospective survey. Large integrated health system with sites in 4 U.S. states. Patients initiating portal message threads and health system providers completing an online survey. E-visit billing was implemented 18 August 2023. The volume of patient-initiated medical advice message threads pre- versus postimplementation of e-visit billing was compared. Health system provider perceptions of e-visit billing were assessed using an online survey. In the 6 months after e-visit billing implementation (18 August 2023 through 18 February 2024), the volume of patient-initiated medical advice message threads decreased by 8.8% (from 1 813 818 to 1 653 708) compared with the same dates the year prior (P = 0.002). A total of 5183 (0.3%) medical advice messages were billed. There was no difference in 7-day use of emergency services (emergency department visits or hospitalizations) in patients who proceeded with sending a message versus those that did not send a message after viewing the billing disclaimer on the patient portal. Providers reported overall acceptance of e-visit billing but expressed concerns about increased workload with the current process. Cannot assess changes in other forms of contact, including telephone calls. These findings suggest that implementation of e-visit billing was associated with a modest decrease in patient-initiated portal message volume and was overall acceptable to providers in a large integrated health system. None.

BACKGROUND COVID-19 worsened an already existing problem in substance use disorder (SUD) treatment. However, it helped transform the use of telehealth, which particularly benefits rural America. The lack of specialty addiction treatment in rural areas places the onus on primary care providers. Screening, brief intervention, and referral to treatment (SBIRT) is an evidenced-based strategy commonly used in primary care settings to target SUD outcomes and related behaviors. The integration of telehealth tools within the SBIRT pathway may better sustain the program in primary care. Building on Mayo Clinic’s experience with collaborative care management (CoCM) for mental health treatment, we built a digitally native, integrated, behavioral health CoCM platform using a novel mobile app and web-based provider platform called Senyo Health. OBJECTIVE This protocol describes a novel use of the SBIRT pathway using Senyo Health to complement existing CoCM integration within primary care to deliver SUD treatment to rural patients lacking other access. We hypothesize that this approach will improve SUD-related outcomes within rural primary care clinics. METHODS Senyo Health is a digital tool to facilitate the use of SBIRT in primary care. It contains a web-based platform for clinician and staff use and a patient-facing mobile phone app. The app includes 16 learning modules along with data collection tools and a chat function for communicating directly with a licensed drug counselor. Beta-testing is currently underway to examine opportunities to improve Senyo Health prior to the start of the trial. We describe the development of Senyo Health and its therapeutic content and data collection instruments. We also describe our evaluation strategy including our measurement plan to assess implementation through a process guided by Consolidated Framework for Implementation Research methods and effectiveness through a waitlist control trial. A randomized controlled trial will occur where 30 participants are randomly assigned to immediately start the Senyo intervention compared to a waitlist control group of 30 participants who will start the active intervention after a 12-week delay. RESULTS The Senyo Health app was launched in May 2023, and the most recent update was in August 2024. Our funding period began in September 2023 and will conclude in July 2027. This protocol defines a novel implementation strategy for leveraging a digitally native, clinical platform that enables the delivery of CoCM to target an SUD-specific patient population. Our trial will begin in June 2025. CONCLUSIONS We present a theory of change and study design to assess the impact of a novel and patient-centered mobile app to support the SBIRT approach to SUD in primary care settings. CLINICALTRIAL ClinicalTrials.gov NCT06743282; http://clinicaltrials.gov/ct2/show/NCT06743282 INTERNATIONAL REGISTERED REPORT PRR1-10.2196/65693