Reducing Stress in Primary Care Patients
Condition: Stress
Study type: Interventional

Summary: 
      Stress and anxiety can worsen quality of life in patients seen in primary care practices.
      This project is set in UPMC primary care practices (CMI) to evaluate how the availability of
      a virtual stress management program can help patients reduce stress and anxiety and improve
      their quality of life. The project will analyze the efficacy of the virtual stress management
      program at these practices so that it can then be utilized effectively in other medical
      settings where it can be offered as a part of clinical care to reduce stress and anxiety and
      improve the quality of life of medical patients who could benefit from a reduction in stress.
      This research is being piloted at these sites in the hopes of publishing results that show
      that it can be implemented in other practices throughout the country.

      Additionally, at other UPMC CMI primary care sites, de-identified data will be collected in
      order to serve as a comparison.
    

Detailed description: 
      All patients who are receiving or seeking medical care at UPMC CMI practices are given the
      GAD7(anxiety) and SF-12(quality of life) as a part of their routine medical care. Since this
      project is occurring at the same practices where a randomized study evaluating treatments for
      acute back pain (IRB Protocol #015120249), patients with acute back pain will be excluded
      from this project.

      Patient scores become part of the EMR (Epic). A best practice alert will be generated for
      patients in the age range of 20-65 (inclusive) and in the targeted GAD7 score range (GAD7 ≥5)
      to prompt the provider to recommend the stress management program (Lantern). The age range
      was chosen to exclude adolescents who may have different needs, and the geriatric population
      who is involved in other behavioral studies at these practices.

      The Best Practice alert will prompt the clinic staff to gather promotional Lantern materials
      and pend an order in Epic for stress management registration. When the clinical staff sees
      the pended order and Lantern materials, clinic staff will decide if the stress management
      program is appropriate for the patient. The discussion will include a disclaimer that the
      stress management program does not offer treatment. Clinical staff and patient will also
      discuss whether or not the patient wishes to consent to participate in Lantern and be
      contacted Lantern. The clinical staff will question the patient about smartphone or tablet
      (specifically, iOS or Android) access/availability during the consent process. If the patient
      is interested, the clinician will submit the order and the patient will sign the consent to
      participate in the stress management program (Lantern). The use of Lantern is set up at these
      two CMI sites as part of this research study. It is not for normal clinical care for UPMC
      patients.

      The order generates a paragraph about the stress management program provided to the patient
      as a written order. The order sends an Epic InBasket to the UPMC Enterprises project team
      (including the patient's MRN, name, date of birth and contact information). When each order
      is received, the UPMC Enterprises project team will enter the patient into the registration
      system, generating a unique ID for each patient.

      The registration system will send out an email message to the third-party stress management
      program (including the unique ID, name, date of birth, and contact information) through a
      secure VPN connection between UPMC Enterprises and Lantern to inform them of people who have
      consented.

      The third-party stress management program vendor, Lantern, will send a welcome message by
      email and text message to each patient consented by the UPMC research team. Patients also
      have the opportunity to directly sign up for Lantern while still in the primary care office.

      Once the patient receives the welcome message by email or text, the patient can begin the
      program on a mobile device. Patients will be self-directed to complete modules of the stress
      management program.

      Within 2-4 weeks after consent, a UPMC research team member will administer via phone a
      brief, approximately 10 minute questionnaire. This DSM5 cross-cutting measure level 1 is a
      validated screening tool capturing primary psychiatric conditions. The DSM5 will only be used
      for participants that score greater than or equal to 10 on the initial GAD7 in clinic or
      through MyUPMC. The techniques to try are available for users to access at any time. The
      coaches are not therapists, but are there to provide information and encouragement to the
      patient. To keep confidentiality, the coach only knows the first name of the patient. The
      coordinator of the coaches has access to the patient's identifying information if the patient
      has an escalation in distress/anxiety that needs to be addressed. This information will be
      passed to the PI when necessary as part of the escalation procedures (as outlined in the
      attachments - Escalation Procedure). The personally identifying information is held
      internally within the Amazon web services at Lantern. The coaches for the patients have
      access to an internal Coaching Portal where the coaches have a dashboard for each user. This
      dashboard includes all information that the user inputs into the Lantern program, including
      both direct messages to coaches and all content completed in the program. Coaches receive a
      notification when users complete a path in the program or send a message, which prompts a
      coach's response to the individual. Users will continue to self-monitor anxiety levels
      throughout the program after learning this skill in the first core component. (See Other
      Attachments - Example Messages from Lantern Coaches to read examples of how the coach
      interacts with the user as well as Sample Lantern Content.)

      The 6 core components include:

        1. Education and awareness about stress and how thoughts, emotions, and behaviors are
           interrelated. This provides the rationale of the cognitive-behavioral model. In this
           unit, patients will learn how to change thoughts and behaviors in order to change
           emotions.

        2. Relaxation - patients learn several empirically supported relaxation techniques to
           manage stress/anxiety.

        3. Thoughts - this unit is about the stories a person tells themselves and how these
           stories determine mood and help to decide what actions to take. This core component also
           guides patients on how to challenge assumptions about these thoughts/stories and how to
           create new stories.

        4. Behavior Change and Exposure - patients will learn how to avoid things that contribute
           to stress and identify adaptive coping activities. Through learning the principle of
           exposure, patients learn how anxiety provoking situations can help to overcome anxiety
           in the long term.

        5. Mindfulness - This unit is about taking a step back from thoughts and feelings to
           interrupt the thoughts-feelings-behaviors cycle. Several mindfulness exercises are
           offered so the patient can find the type that feels best.

        6. Habit Formation/Maintaining Skills - Patients will reflect on what has been learned and
           work on making a habit out of the most effective techniques.

      Lantern, the third-party program provider, will collect de-identified usage data (e.g.,
      progression through the program, frequency of messages to coaches, and techniques completed)
      and quantitative data (e.g. self-monitoring anxiety score responses) as the patient
      progresses through the program. Lantern internally has a database that tracks user progress
      through the program, so Lantern can understand how patients have moved through the program.
      This de-identified data will be sent to the UPMC study staff coded only with the patient's
      unique ID.

      Lantern will also generate usage data reports at regular intervals . The subject progression
      through Lantern is being fed into the research database from Lantern. These reports will also
      be coded by the patient's unique ID. The research team will send the usage progress report to
      EPIC to be included in the patient's medical record as a PDF.

      At several time-points, Lantern will push self-reported validated questionnaires to patients
      enrolled in Lantern via a Qualtrics account. Lantern's Qualtric's account is a third party,
      HIPAA compliant survey tool. Thrive Network Inc. has a business associate agreement (BAA)
      with Lantern's Qualtric's account and owns all data collected through surveys.

      Lantern's Qualtrics Account will push GAD7's and one additional item asking about
      satisfaction with the program to subjects. At 6 months post enrollment, participants at
      active (Lantern) sites will be sent a Qualtrics questionnaire with the GAD7, SF-12, Health
      Anxiety Sub-scale, Medical Utilization/Follow-up Questionnaire, and Patient Satisfaction
      questions. The purpose of the Health Anxiety Sub-scale is to evaluate how Health Anxiety
      changes may differ or are similar to GAD7 changes, and what impact both have on health care
      utilization.

      In addition to the above assessment time points, patients will be pushed a GAD7 assessment
      via Qualtrics within one month of completing the Lantern program.

      If the participant does not complete the Qualtrics survey at 6,and 12 months, the research
      team will contact the patient to prompt completion and offer to administer the measures over
      the phone. If a patient does not complete all of the modules of the Lantern program within a
      designated period of time, the patient will still be asked to fill out the questionnaires. In
      addition to these questionnaires, the research team will also access Epic records to
      understand medical utilization.

      For this study, all patient responses through Lantern's Qualtrics account will be
      deidentified and stored within Lantern's Qualtrics account. Lantern will then share that
      deidentifed data with the UPMC clinical team using patient unique ID numbers. Lantern's
      coaches will not have access to any of the information collected via Qualtrics. Data from
      Qualtrics is pushed to the UPMC study database. GAD7 scores and participant program status
      will be sent in monthly enrollment reports to physicians and not be included as part of the
      electronic medical record (EPIC), unless a patient scores greater than or equal to 15, an
      In-Basket message is sent to the physician via Epic.

      A secure database will be maintained within the UPMC firewall where all patient information
      will be de-identified. CARe will serve as the honest broker. Lantern will have access to
      Lantern's Qualtrics account - delivered surveys (tracked only by unique ID) but will not have
      access to any UPMC patient medical information.

      A subset of patients (n=24) who were offered the Lantern program will be asked to participate
      in an in-depth qualitative telephone interview at 6 months after enrollment. Participants
      will be randomly selected and be balanced to include both those who completed or did not
      complete the program. The interviews will be completed by research staff contacting the
      randomly selected subjects. The qualitative interview will explore patient's experience with
      the program and areas of suggested improvement. All interviews will be audio-recorded and
      transcribed verbatim.

      Comparison Sites: All patients who are receiving or seeking medical care at UPMC CMI
      comparison sites will not sign a consent form. Their information will be a medical record
      review of de-identified data in a limited dataset format from an honest broker.
    

Intervention name(s): Lantern
Intervention type(s): Behavioral
Intervention description(s): This pilot will evaluate how the availability of a virtual stress management resource can help patients reduce anxiety and improve quality of life.
Intervention model: Single Group Assignment
Masking: None (Open Label)
Primary purpose: Other
Keywords: anxiety; behavioral app