First year death rates remain unacceptable high for the end-stage renal disease (ESRD) population. New effective methods are vital to improve first year morbidity and mortality outcomes for the population transitioning from Stage 4 chronic kidney disease (CKD) to ESRD)/Stage 5 CKD. Based on current methods, evidence-based recommendations made by nephrology providers are frequently not heeded by patients in Stage 4 CKD. Low levels of patient knowledge, self-efficacy, and a poor ability to self-manage CKD negatively influence a patient’s ability to follow provider recommendations. The group visit (GV) intervention has demonstrated improvements in disease-related outcomes through increased levels of patient knowledge, self-efficacy, and disease self-management for other chronic diseasses such as diabetes and congestive heart failure (CHF). No data are available for the use of GVs in CKD The purpose of the study was to develop and test a nurse practitioner-facilitated chronic CKD GV model versus usual nephrology care for Stage 4 CKD patients (knowledge, selfefficacy/self-management, physiological data, and satisfaction). As classified by the National Kidney Foundation’s (NKF) staging system, Stage 4 CKD is considered severe kidney disease, with a decrease in the functional capacity of the kidney as determined by a glomerular filtration rate (GFR) of 15-30 ml/min. It is common for patients with Stage 4 CKD to progress to Stage 5 CKD/end-stage renal disease (ESRD), requiring dialysis or transplantation to survive. Preliminary instrumentation and feasibility studies were conducted prior to a pilot study of a CKD GV model. The development and validation of the Stage 4 CKD Knowledge Instrument was completed with 59 Stage 4 patients. Findings supported reliability (KuderRichardson-20 [KR] = .89) and content validity (I-CVI = .97, S-CVI= 1.0) Feasibility of the CKD GV model was assessed with a single group, pretest-posttest design using a convenience iv sample of eight Stage 4 patients. Results demonstrated an improvement in knowledge of CKD from a median of 69% to 86% (p =.012). No improvements were noted in self-efficacy scores (p = .230). GV satisfaction ranged from very good to excellent. Feasibility was supported by a high retention rate (100%). No barriers to participant recruitment or GV implementation were encountered. The pilot study used a two-group, repeated measures experimental design, with a sample of 30 Stage 4 CKD patients from two office locations of an outpatient nephrology practice. Patients were randomized to the GV intervention or to usual nephrology care. CKD-knowledge, self-efficacy, and self-management scores were collected at baseline, six months, and nine months. Physiological data were measured at baseline, six months, and nine months. GV satisfaction was obtained after the completion of GVs (six months). Nephrology practice satisfaction was obtained from by both groups at nine months. MANOVA for repeated measures was calculated for data collected at the three time points. Twenty-six of 30 patients completed the study, with four patients ineligible to complete the study due to progression to ESRD and dialysis initiation. GV attendance was 92%. CKD knowledge was statistically improved for both groups (F(1.498, 34.446) = 6.363, P = .008). While not statistically significant, a favorable upward trend in the mean scores for the subscales of self-management (communication, partnership in care, and self-care) was demonstrated in the GV patients, with a lack of improvement found in the usual care group for these subscales. Selfefficacy scores revealed a non-significant improvement in mean scores for the GV patients during the GVs, not seen with usual care patients. GV satisfaction was again high with the vast majority of patients requesting use of GVs in their future nephrology care. v Current methods of intervention in the Stage 4 CKD population have made little impact on reducing first-year ESRD mortality and morbidity rates. Opportunities to intervene in the poor outcomes begin in the predialysis care of Stage 4 patients. Based on the documented success of multidisciplinary approaches in predialysis care, of GVs in other chronic diseases, and of chronic illness care based on the CCM, a high probability for success exists with the application of GVs in CKD. Although limited by a small sample size, promising improvements in the subscales of disease self-management, self-efficacy, CKD knowledge, and high satisfaction with the GV model for GV participants were revealed in this study. Further research is warranted for the CKD GV model on a larger randomized sample in other locations. Much needed data would be provided on which to base decisions for use of the CKD GV intervention in the predialysis care of Stage 4 patients.

It is currently estimated that over one-third of children aged 6-11 years in the United States are overweight or obese with some of the highest rates documented in Southern Appalachia. Primary care providers are uniquely positioned to intervene, however, lack of time as well as training and confidence in using behavioral techniques have been cited as barriers. Recommended strategies include use of a multidisciplinary team approach, family-centered communication, behavioral strategies, and care delivery following the chronic care model, including enhancement of parent self-management. The purpose of this study was to develop and evaluate a parent-mediated approach utilizing physician’s brief motivational interviewing and parent group sessions to treat child overweight and obesity in the primary care setting in Southern Appalachia. The current study enrolled 67 children (5-11 years) with BMI≥85th percentile and a parent/primary caregiver from four primary care practices in Southern Appalachia. The two participating Pediatric practices and two Family Medicine practices were randomized to intervention or usual care control groups. Providers in the intervention group were trained to deliver two individual visits, using brief motivational interviewing and following the AAP 15-minutes obesity prevention protocol, and four group visits using the NIH We Can! Curriculum with parents over an 8-10 week period. Trained study staff also completed four phone calls using brief motivational interviewing with parents following each group visit. Child weight and height and parent surveys were collected for both intervention and control groups at baseline, three, and six months. Additionally, parents in the intervention group completed We Can! surveys at baseline and following the fourth group session. An analysis of covariance (ANCOVA) was performed to test for the effect of treatment on zBMI at three and six months post-intervention. We Can! survey results were analyzed using paired t-tests. Data on 53 (82%) and 46 (69%) of participants was available at 3 and 6 months, respectively. While the point estimate of the treatment effect was in the expected direction, the effect of treatment assignment did not have a statistically significant effect on the zBMI at either three or six months. However, significant (p This study provides preliminary data on the use of a combination of individual and group visits with parents to treat overweight and obesity in children in primary care.

BACKGROUND: Disparities in access to quality chronic pain treatment options disproportionately affect minorities. Although there is increasing evidence about the effectiveness of complementary and integrative medicine (CIM) to help in the treatment of pain, little is known about how low income minorities would benefit from having greater access to CIM. The Integrative Medical Group Visit (IMGV) model incorporates CIM in a medical group visit setting with the goal of increasing access to CIM. OBJECTIVE: The aims of this pilot study were to test 1) the feasibility of a Spanish language IMGV and 2) its effectiveness to reduce pain and improve function in Spanish speakers with chronic pain. METHODS: The study setting is the Family Medicine Clinic at Boston Medical Center. Adult Spanish speakers with chronic pain for at least 12 weeks were included; those pregnant, with psychosis, suicidal ideation or active substance abuse disorder were excluded. The intervention consisted of weekly, two-hour sessions for a total of 9 weeks. Main outcomes were pain level, pain interference, and physical and emotional function measured by the PROMIS 29 pre- and post-intervention, depression and stress, measured by PHQ-8 and PSS-10, respectively. Focus group participants discussed the feasibility of the intervention. Analyses involved t-tests to examine our outcome data, and qualitative thematic analysis for focus group data. RESULTS: This open study recruited 11 subjects, 10 women, average age of 51.9 years; 50% of participants attended more than four sessions. The outcomes showed a trend toward reduced depression, pain, fatigue, and anxiety. Qualitative themes of reduced pain, increased knowledge for healthier living, and improved access to pain treatment using an appropriately adapted intervention were found. CONCLUSIONS: It was feasible to implement the Latino IMGV model in the outpatient setting at BMC. Trends in reduction of pain and depression, as well as increased knowledge for healthier living and better access to CIM modalities were found. Future powered studies are needed to further implement this model.

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