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April 2001 - present
Publications
Publications (144)
Objective
To prospectively evaluate the relationship between cumulative environmental stress and cardiometabolic risk in middle childhood, and to examine whether hair cortisol, a measure of hypothalamic pituitary adrenal‐axis activity, mediates this relationship.
Methods
In a cohort of children from low‐income households ( n = 320; 59% Hispanic, 2...
Rationale & Objective
The study aimed to develop, implement, and evaluate a clinical decision support (CDS) system for chronic kidney disease (CKD) in a primary care setting, with the goal of improving CKD care in adults.
Study Design
This was a cluster randomized trial.
Setting & Participants
A total of 32 Midwestern primary care clinics were ra...
Objective: To measure the impact of a clinical decision support (CDS) tool on total modifiable cardiovascular risk at 12 months separately for outpatients with 3 subtypes of serious mental illness (SMI) identified via ICD-9 and ICD-10 codes: bipolar disorder, schizoaffective disorder, and schizophrenia. Methods: This cluster-randomized pragmatic cl...
Background:
Many primary care clinicians (PCCs) hold stigma toward people with opioid use disorder (OUD), which may be a barrier to care. Few interventions exist to address PCC stigma toward people with OUD. This study examined whether an online training incorporating patient narratives reduced PCCs' stigma toward people with OUD (primary) and inc...
Background
The early detection and management of uncontrolled cardiovascular risk factors among prediabetes patients can prevent cardiovascular disease (CVD). Prediabetes increases the risk of CVD, which is a leading cause of death in the United States. CVD clinical decision support (CDS) in primary care settings has the potential to reduce cardiov...
Background
Opioid-related deaths continue to rise in the U.S. A shared decision-making (SDM) system to help primary care clinicians (PCCs) identify and treat patients with opioid use disorder (OUD) could help address this crisis.
Methods
In this cluster-randomized trial, primary care clinics in three healthcare systems were randomized to receive o...
Background
A team approach is one of the most effective ways to lower blood pressure (BP) in uncontrolled hypertension, but different models for organizing team-based care have not been compared directly.
Methods
A pragmatic, cluster-randomized trial compared 2 interventions in adult patients with moderately severe hypertension (BP≥150/95 mm Hg):...
Background
Explanatory trials are designed to assess intervention efficacy under ideal conditions, while pragmatic trials are designed to assess whether research-proven interventions are effective in “real-world” settings without substantial research support.
Methods
We compared two trials (Hyperlink 1 and 3) that tested a pharmacist-led telehealt...
A total of 513 children were included in this secondary analysis of data from the NET-Works trial of low income children at risk for obesity. The purpose of the analysis was to examine HCC longitudinally over 5 assessments from early through middle childhood with the goal of i) determining if there were racial/ethnic differences in HCC, and if so,...
Background
Hypertension control is falling in the US yet efficacious interventions exist. Poor patient reach has limited the ability of pragmatic trials to demonstrate effectiveness. This paper uses quantitative and qualitative data to understand factors influencing reach in Hyperlink 3, a pragmatic hypertension trial testing an efficacious pharmac...
Objective
This study assessed the relationship of both depression diagnosis and clinically significant depressive symptoms with individual cardiovascular risk factors and estimated total cardiovascular risk in primary care patients.
Methods
This study used a cross-sectional and retrospective design. Patients who had a primary care encounter betwee...
Background
To compare estimated 10‐year and 30‐year cardiovascular risk in primary care patients with and without serious mental illness (SMI; bipolar disorder, schizophrenia, or schizoaffective disorder).
Methods and Results
All patients aged 18 to 75 years with a primary care visit in January 2016 to September 2018 were included and were grouped...
Importance:
Adults with schizophrenia, schizoaffective disorder, or bipolar disorder, collectively termed serious mental illness (SMI), have shortened life spans compared with people without SMI. The leading cause of death is cardiovascular (CV) disease.
Objective:
To assess whether a clinical decision support (CDS) system aimed at primary care...
Background
Early detection of prediabetes and management of cardiovascular (CV) risk factors to prevent CV disease is essential, but clinicians are often slow to address this risk. Clinical decision support (CDS) systems, with appropriate implementation, can potentially improve prediabetes identification and treatment.
Methods/design
34 Midwestern...
Objective
Most Americans with opioid use disorder (OUD) do not receive indicated medical care. A clinical decision support (CDS) tool for primary care providers (PCPs) could address this treatment gap. Our primary objective was to build OUD-CDS tool and demonstrate its functionality and accuracy. Secondary objectives were to achieve high use and ap...
Background:
Hypertension control has been decreasing recently. We compared the experience and attitudes toward care between patients with uncontrolled hypertension who are more and less satisfied with that care to identify ways to improve their care.
Methods:
Baseline survey of 3072 patients with diagnosed hypertension and repeated blood pressur...
Background
State-of-the-art behavioral weight loss treatment (SBT) can lead to clinically meaningful weight loss, but only 30–60% achieve this goal. Developing adaptive interventions that change based on individual progress could increase the number of people who benefit.
Purpose
Conduct a Sequential Multiple Assignment Randomized Trial (SMART) to...
Background
We describe a clinic-randomized trial to improve chronic kidney disease (CKD) care through a CKD-clinical decision support (CKD-CDS) intervention in primary care clinics and the challenges we encountered due to COVID-19 care disruption.
Methods/design
Primary care clinics (N = 32) were randomized to usual care (UC) or to CKD-CDS. Betwee...
Purpose: We designed, implemented, and evaluated impact of a prediabetes clinical decision support system on identification of prediabetes and control of major cardiovascular (CV) risk factors in adults with prediabetes receiving care in primary care clinics.
Methods: We randomized 34 primary care clinics with 18,229 study-eligible patients age 40-...
Introduction: Patient ratings of their experience of care are part of the “Triple Aim”. Improvements are highly valued by health care organizations, but are hard to achieve.
Hypothesis: We tested the effect of a telehealth intervention on satisfaction with hypertension care.
Methods: Hyperlink 3 is an ongoing pragmatic cluster-randomized trial in 3...
Introduction: Telehealth and remote monitoring have become critical to patient access to care during the COVID-19 pandemic. We measured the effect of a telehealth care intervention on frequency, sharing methods, and clinical usage of home blood pressure (BP) measurements.
Methods: Hyperlink 3 is an ongoing pragmatic cluster-randomized trial in 3072...
Background: Evidence-based chronic kidney disease (CKD) care can slow progression and avert complications. We evaluated evidence-based care gaps for stage 3 and 4 CKD in patients with and without diabetes (DM).
Methods: All patients age 18-75 with a primary care encounter between April and October 2019 in any of 32 clinics in a large Midwestern car...
Background:
Cardiovascular (CV) disease is the leading cause of death for people with serious mental illness (SMI), but clinicians are often slow to address this risk.
Methods/design:
78 Midwestern primary care clinics were randomized to receive or not receive access to a clinical decision support (CDS) tool. Between March 2016 and September 201...
Background:
Uncontrolled hypertension is the largest single contributor to all-cause and cardiovascular mortality in the U.S.
Population:
Nurse- and pharmacist-led team-based care and telehealth care interventions have been shown to result in large and lasting improvements in blood pressure (BP); however, it is unclear how successfully these can...
Background
Pediatric primary care is an important setting for addressing obesity prevention.
Objective
The Healthy Homes/Healthy Kids 5‐10 randomized controlled trial evaluated the efficacy of an obesity prevention intervention integrating pediatric primary care provider counseling and parent‐targeted phone coaching.
Methods
Children aged 5 to 10...
Objectives:
To evaluate a multicomponent obesity prevention intervention among diverse, low-income preschoolers.
Methods:
Parent-child dyads (n = 534) were randomized to the Now Everybody Together for Amazing and Healthful Kids (NET-Works) intervention or usual care in Minneapolis, MN (2012-2017). The intervention consisted of home visits, paren...
The 2017 ACC/AHA hypertension guideline strongly recommends systematic follow-up and monitoring of treatment using team-based care and telehealth, based on Level A evidence. However, different models for organizing team-based care and telehealth have not been compared. We describe the design of a PCORI-funded pragmatic trial with the following obje...
Objective:
To test the hypothesis that use of a clinical decision support (CDS) system in a primary care setting can reduce cardiovascular (CV) risk in patients.
Materials and methods:
Twenty primary care clinics were randomly assigned to usual care (UC) or CDS. For CDS clinic patients identified algorithmically with high CV risk, rooming staff...
Background: Our objective was to assess the impact on primary care of the 2017 ACC/AHA lowering of the threshold for diagnosing HTN to a BP ≥ 130/80 mm Hg, and pharmacologic treatment intensification recommendations for patients with high CV risk and/or DM who have BP levels 130-139/80-89 mm Hg.
Discussion: 62% of patients with DM and 57% without D...
(Reprinted with permission from General Hospital Psychiatry 44 (2017) 77-85).
Background
An important step toward enhancing the efficacy of weight loss maintenance interventions is identifying the pathways through which successful interventions such as the Keep It Off trial have worked. PurposeThis study aimed to assess the viability of mediated relationships between the Keep It Off Guided intervention, conceptually and empi...
To the Editor The Viewpoint by Drs Mora and Manson¹ in a recent issue of JAMA Internal Medicine recognizes that aspirin use for primary prevention of atherosclerotic cardiovascular disease (ASCVD) needs to be highly individualized to accurately balance benefits and risks. They suggest a practical approach to aid clinicians with calculating ASCVD an...
The ability to aggregate clinical data across multiple diverse organizations and to use it for performance measurement, quality improvement, evaluation, and research is rapidly becoming a national necessity, but there are few examples of how to do that. This article uses lessons from a national effort to implement the collaborative care management...
Background
While health systems are striving for patient-centered care, they have little evidence to guide them on how to engage patients in their care, or how this may affect patient experiences and outcomes.
Objective
To explore which specific patient-centered aspects of care were best associated with depression improvement and care satisfaction...
Background/Aims: The U.S. Preventive Services Task Force (USPSTF) currently recommends aspirin for primary prevention of coronary heart disease in men 45–79 years old and strokes in women 55–79 years old when the potential cardiovascular disease benefit outweighs the potential harm of gastrointestinal hemorrhage. The complexity and time required to...
Background/Aims: Cardiovascular (CV) Wizard is a web-based electronic health record-integrated point-of-care clinical decision support (CDS) system that presents personalized CV risk information to providers and patients in both a low-numeracy visual format and a high-numeracy quantitative format. We report primary care provider perspectives on how...
Background/Aims: To identify key design features of point-of-care diabetes clinical decision support (CDS) that have high use rates and high provider satisfaction rates, and that have improved control of major cardiovascular risk factors.
Methods: Based on a series of National Institutes of Health-funded projects to develop point-of-care electronic...
Objective:
The spread of evidence-based care is an important challenge in healthcare. We evaluated spread of an evidence-based large-scale multisite collaborative care model for patients with depression and diabetes and/or cardiovascular disease (COMPASS).
Methods:
Primary care patients with depression and comorbid diabetes or cardiovascular dis...
Background:
Little is known about the reach and impact of collaborative care for depression outside of clinical trials.
Objective:
The objective of this study was to examine the effect of a collaborative care intervention for depression on the rates of depression diagnosis, use of specific depression codes, and treatment intensification.
Resear...
Objective:
Depression is pervasive and costly, and the majority of depression is treated in primary care. The objective of this study was to identify patient characteristics predictive of poor depression outcomes in primary care clinics.
Methods:
This observational study followed 792 patients receiving usual care for depression in 83 clinics acr...
Objective:
To describe primary care clinicians' self-reported satisfaction, burnout and barriers for treating complex patients.
Methods:
We conducted a survey of 1554 primary care clinicians in 172 primary care clinics in 18 health care systems across 8 states prior to the implementation of a collaborative model of care for patients with depress...
Behavioral weight loss programs help people achieve clinically meaningful weight losses (8–10% of starting body weight). Despite data showing that only half of participants achieve this goal, a “one size fits all” approach is normative. This weight loss intervention science gap calls for adaptive interventions that provide the “right treatment at t...
Background:
The Healthy Homes/Healthy Kids Preschool (HHHK-Preschool) pilot program is an obesity prevention intervention integrating pediatric care provider counseling and a phone-based program to prevent unhealthy weight gain among 2- to 4-year-old children at risk for obesity (BMI percentile between the 50th and 85th percentile and at least one...
Purpose:
Scale-up and spread of evidence-based practices is one of the most important challenges facing health care. We tested whether a statewide initiative, Depression Improvement Across Minnesota-Offering a New Direction (DIAMOND), to implement the collaborative care model for depression in 75 primary care clinics resulted in patient outcome im...
Background/Aims: Achieving and maintaining high rates of use of clinical decision support in primary care settings has been challenging. Our goal was to reach and maintain high use rates throughout the study period through ongoing feedback and incentives to clinics and consented providers.
Methods: We conducted a clinic randomized trial of an elect...
Background/Aims: Our goal was to evaluate provider experience with an electronic health record (EHR)-based clinical decision support (CDS) tool called CV Wizard implemented as part of a large randomized trial with 80% use rates for eligible patients. The tool included a quantitative “provider” form with prioritized treatment suggestions and a simpl...
To describe the proportion of children adhering to recommended physical activity and dietary guidelines, and examine demographic and household correlates of guideline adherence.
Cross-sectional (pre-randomization) data from a behavioral intervention trial designed to prevent unhealthy weight gain in children.
A total of 421 children (aged 5-10 year...
Background
Depression is a major cause of morbidity and cost in primary care patient populations. Successful depression improvement models, however, are complex. Based on organizational readiness theory, a practice¿s commitment to change and its capability to carry out the change are both important predictors of initiating improvement. We empirical...
Background/Aims: The collaborative care model for primary care of depression has a very strong evidence base, but has been little implemented. A statewide initiative (called DIAMOND) to implement it widely in Minnesota along with a new payment provided an opportunity for an embedded partnership research study of its implementation and impacts on th...
Background:
Although the prevalence of obesity in young children highlights the importance of early interventions to promote physical activity (PA), there are limited data on activity patterns in this age group. The purpose of this study was to describe activity patterns in preschool-aged children and explore differences by weight status.
Methods...
Objectives Depression is associated with lowered work functioning, including absence, productivity impairment at work, and decreased job retention. Although high-quality depression treatment provided in clinical trials has been found to reduce symptoms and improve work function, the effectiveness of routine treatment for depression in primary care...
Background:
Little is known about the most important organizational factors and strategies for transforming primary care clinics into patient-centered medical homes (PCMHs), so we studied this in newly certified medical homes in Minnesota.
Methods:
We collected the following information from the first 120 clinics serving adults to be certified:...
To examine relationships between parenting styles and practices and child moderate-to-vigorous physical activity (MVPA) and screen time.
Participants were children (6.9 ± 1.8 years) with a body mass index in the 70-95th percentile and their parents (421 dyads). Parent-completed questionnaires assessed parental support for child physical activity (P...
Objective. To investigate the relationship between binge eating behavior and weight loss maintenance over a two-year period in adults. Design. Secondary data analysis using the Keep It Off study, a randomized trial evaluating an intervention to promote weight loss maintenance. Participants. 419 men and women (ages: 20 to 70 y; BMI: 20–44 kg/m2) who...
There is limited information about how to transform primary care practices into medical homes. The research team surveyed leaders of the first 132 primary care practices in Minnesota to achieve medical home certification. These surveys measured priority for transformation, the presence of medical home practice systems, and the presence of various o...
Objectives:
This study investigated the relationship between parental concern about child weight and weight-related child behaviors, parenting practices, and household characteristics.
Methods:
Parent-child dyads (N=421) enrolled in a randomized, controlled obesity prevention trial were evaluated at baseline.
Results:
Parental concern regardin...
Shared decision making (SDM) is an important component of patient-centered care, but there is little information about its use in the primary care of depression, so we sought to study its frequency in usual care as reported by patients.
Telephone interview of 1168 depressed patients taking antidepressants in 88 Minnesota primary care clinics who we...
To compare between accelerometry (MVPA-A) and self-reported activity (MVPA-SR) in activity-maintenance (Keep Active Minnesota; KAM) and weight loss-maintenance (Keep It Off; KIO) trials.
Linear regression estimated moderation of study, treatment, or time on MVPA-A and MVPA-SR associations.
MVPA-A was similar between studies (KAM 119 minutes, KIO 11...
This study aims to determine the positive and negative predictive values of self-reported diabetes during the Women's Health Initiative (WHI) clinical trials.
All WHI trial participants from four field centers who self-reported diabetes at baseline or during follow-up, as well as a random sample of women who did not self-report diabetes, were ident...
To document the role job control and schedule control play in shaping women's physical activity, and how it delineates educational and racial variability in associations of job and social control with physical activity.
Prospective data were obtained from a community-based sample of working women (N = 302). Validated instruments measured job contro...
The many randomized trials of the collaborative care model for improving depression in primary care have not described the implementation and maintenance of this model. This paper reports how and the degree to which collaborative care process changes were implemented and maintained for the 75 primary care clinics participating in the DIAMOND Initia...
Background/Aims More than 30% of adults in the U.S. have a 10% risk or greater of having a heart attack in the next 10 years. The proportion of adults with moderate and high cardiovascular risk (CVR) accounts for nearly half of the first major cardiovascular (CV) events in the United States. Shared decision support tools may reduce CVR by facilitat...
Pediatric primary care is an important setting in which to address obesity prevention, yet relatively few interventions have been evaluated and even fewer have been shown to be effective. The development and evaluation of cost-effective approaches to obesity prevention that leverage opportunities of direct access to families in the pediatric primar...
Immunizations are crucial to the prevention of disease, thus, having an accurate measure of vaccination status for a population is an important guide in targeting prevention efforts. In order to comprehensively assess the validity of self-reported adult vaccination status for the eight most common adult vaccines we conducted a survey of vaccination...
Purpose:
The patient-centered medical home is often discussed as though there exist either traditional practices or medical homes, with marked differences between them. We analyzed data from an evaluation of certified medical homes in Minnesota to study this topic.
Methods:
We obtained publicly reported composite measures for quality of care out...
Objective:
The Keep It Off trial evaluated the efficacy of a phone-based weight loss maintenance intervention among adults who had recently lost weight in Minnesota (2007-2010).
Methods:
419 adults who had recently lost ≥ 10% of their body weight were randomized to the "Guided" or "Self-Directed" intervention. Guided participants received a 10 s...
Introduction. Racial differences in women's regular physical activity are well documented, but explanations are elusive. Characteristics of paid work, specifically control over when and how work is done and schedule control, are frequently overlooked in studies of physical activity habits.
Method. Pedometer data were obtained four-times across a...
The Survey of Organizational Research Climate (SORC) is a validated tool to facilitate promotion of research integrity and research best practices. This work uses the SORC to assess shared and individual perceptions of the research climate in universities and academic departments and relate these perceptions to desirable and undesirable research pr...
Development and targeting efforts by academic organizations to effectively promote research integrity can be enhanced if they are able to collect reliable data to benchmark baseline conditions, to assess areas needing improvement, and to subsequently assess the impact of specific initiatives. To date, no standardized and validated tool has existed...
Purpose:
Caring for a family member with dementia is associated with chronic stress, which can have significant deleterious effects on caregivers. The purpose of the Balance Study was to compare a mindfulness-based stress reduction (MBSR) intervention to a community caregiver education and support (CCES) intervention for family caregivers of peopl...
Objective:
To demonstrate a rigorous methodology that optimally balanced internal validity with generalizability to evaluate a statewide collaborative that implemented an evidence-based, collaborative care model for depression management in primary care.
Study design and setting:
Several operational features of the DIAMOND (Depression Improvemen...
Depression is associated with lowered work functioning, including absences, impaired productivity, and decreased job retention. Few studies have examined depression symptoms across a continuum of severity in relationship to the magnitude of work impairment in a large and heterogeneous patient population, however. We assessed the relationship betwee...
Practice system tools improve chronic disease care, but are generally lacking for the care of depression in most primary care settings.
To describe the frequency of various depression-related practice system tools among Minnesota primary care clinics interested in improving depression care.
Cross-sectional survey.
Physician leaders of 82 clinics in...
Caregivers for a family member with dementia experience chronic long-term stress that may benefit from new complementary therapies such as mindfulness-based stress reduction. Little is known however, about the challenges of recruiting and retaining family caregivers to research on mind-body based complementary therapies. Our pilot study is the firs...
Objective. To determine the accuracy of self-reported body weight prior to and following a weight loss intervention including daily self-weighing among obese employees.
Methods. As part of a 6-month randomized controlled trial including a no-treatment control group, an intervention group received a series of coaching calls, daily self-weighing, an...
Background/Aims: Increasing concerns about cognitive decline and dementia in the aging populations of most westernized countries suggests the need for interventions that can preserve cognitive function, are cost-effective, and feasibly implemented on a large scale. Empirical evidence is accumulating that points to the potential beneficial effects o...
To build upon state-of-the-art theory and empirical data to estimate the strength of multiple mediators of the efficacious Keep Active Minnesota (KAM) physical activity (PA) maintenance intervention.
The total, direct, and indirect effects through which KAM helped randomized participants (KAM n = 523; UC n = 526) maintain moderate or vigorous PA (M...
The professional behavior of scientists, for good or ill, is likely associated with their perceptions of whether they are treated fairly in their work environments, including their academic department and university and by relevant regulatory bodies. These relationships may also be influenced by their own personal characteristics, such as being ove...
Translational research is increasingly important as academic health centers transform themselves to meet new requirements of National Institutes of Health funding. Most attention has focused on T1 translation studies (bench to bedside) with considerable uncertainty about how to enhance T2 (effectiveness trials) and especially T3 (implementation stu...
To evaluate the efficacy at 6-, 12-, and 24-month follow-up of Keep Active Minnesota (KAM), a telephone and mail-based intervention designed to promote physical activity (PA) maintenance among currently active adults age 50 to 70.
Participants who reported having recently increased their MVPA to a minimum of 2d/wk, 30 min/bout, (N=1049) were recrui...
Background: A1c results are often not available until after the outpatient visit is completed. Despite the potential for rapid point- of- care (POC) A1c testing to improve the process of diabetes care, published results have not conclusively shown a link to improved diabetes care in primary care settings. Methods: All HealthPartners Medical Group p...
Introduction: While it is well documented that disparities exist across racial groups of diabetes patients relative to glucose control, the underlying causative factors are not well understood. The purpose of this study was to examine differences in physician orders for adjustments of glucose control medications in diabetes patients between African...
To assess the representativeness of older adults recruited to a physical activity maintenance RCT by conducting sequential comparisons to characterize study sample composition changes occurring between sampling frame construction and study enrollment.
Study subjects (N = 1049) were 50 to 70 year old men and women who had increased physical activity...
Private industry involvement is viewed as tainting research with self-interest, whereas public funding is generally well regarded. Yet, dependence on "soft money" also triggers researcher and university self-interest. No empirical research has compared these factors' effects on academic researchers' behaviors.
In 2006-2007, a survey was mailed to 5...
Antidepressant use in US adults increased 3-fold from 2.5% in 1988-94 to 8.1% in 1999-2002, based on National Health and Nutrition Examination Surveys. As the use of antidepressants increases, a comprehensive understanding of the potential health risks that may be associated with their use becomes increasingly important. This study evaluated the ef...
