BackgroundChronic pain, especially back pain, is a prevalent condition that is associated with disability, poor health status, anxiety and depression, decreased quality of life, and increased health services use and costs. Current evidence suggests that exercise is an effective strategy for managing chronic pain. However, there are few clinical programs that use generally available tools and a relatively low-cost approach to help patients with chronic back pain initiate and maintain an exercise program.ObjectiveThe objective of the study was to determine whether a pedometer-based, Internet-mediated intervention can reduce chronic back pain-related disability.MethodsA parallel group randomized controlled trial was conducted with 1:1 allocation to the intervention or usual care group. 229 veterans with nonspecific chronic back pain were recruited from one Department of Veterans Affairs (VA) health care system. Participants randomized to the intervention received an uploading pedometer and had access to a website that provided automated walking goals, feedback, motivational messages, and social support through an e-community (n=111). Usual care participants (n=118) also received the uploading pedometer but did not receive the automated feedback or have access to the website. The primary outcome was measured using the Roland Morris Disability Questionnaire (RDQ) at 6 months (secondary) and 12 months (primary) with a difference in mean scores of at least 2 considered clinically meaningful. Both a complete case and all case analysis, using linear mixed effects models, were conducted to assess differences between study groups at both time points.ResultsBaseline mean RDQ scores were greater than 9 in both groups. Primary outcome data were provided by approximately 90% of intervention and usual care participants at both 6 and 12 months. At 6 months, average RDQ scores were 7.2 for intervention participants compared to 9.2 for usual care, an adjusted difference of 1.6 (95% CI 0.3-2.8, P=.02) for the complete case analysis and 1.2 (95% CI -0.09 to 2.5, P=.07) for the all case analysis. A post hoc analysis of patients with baseline RDQ scores ≥4 revealed even larger adjusted differences between groups at 6 months but at 12 months the differences were no longer statistically significant.ConclusionsIntervention participants, compared with those receiving usual care, reported a greater decrease in back pain-related disability in the 6 months following study enrollment. Between-group differences were especially prominent for patients reporting greater baseline levels of disability but did not persist over 12 months. Primarily, automated interventions may be an efficient way to assist patients with managing chronic back pain; additional support may be needed to ensure continuing improvements.Trial RegistrationClinicalTrials.gov NCT00694018; http://clinicaltrials.gov/ct2/show/NCT00694018 (Archived by WebCite at http://www.webcitation.org/6IsG4Y90E).

IMPORTANCE Older patients with diabetes mellitus receiving medical treatment whose blood pressure (BP) or blood glucose level are potentially dangerously low are rarely deintensified. Given the established risks of low blood pressure and blood glucose, this is a major opportunity to decrease medication harm. OBJECTIVE To examine the rate of BP-and blood glucose-lowering medicine deintensification among older patients with type 1 or 2 diabetes mellitus who potentially receive overtreatment. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study conducted using data from the US Veterans Health Administration. Participants included 211 667 patients older than 70 years with diabetes mellitus who were receiving active treatment (defined as BP-lowering medications other than angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, or glucose-lowering medications other than metformin hydrochloride) from January 1 to December 31, 2012. Data analysis was performed December 10, 2013, to July 20, 2015. EXPOSURES Participants were eligible for deintensification of treatment if they had low BP or a low hemoglobin A 1c (HbA 1c) level in their last measurement in 2012. We defined very low BP as less than 120/65 mm Hg, moderately low as systolic BP of 120 to 129 mm Hg or diastolic BP (DBP) less than 65 mm Hg, very low HbA 1c as less than 6.0%, and moderately low HbA 1c as 6.0% to 6.4%. All other values were not considered low. MAIN OUTCOMES AND MEASURES Medication deintensification, defined as discontinuation or dosage decrease within 6 months after the index measurement. RESULTS The actively treated BP cohort included 211 667 participants, more than half of whom had moderately or very low BP levels. Of 104 486 patients with BP levels that were not low, treatment in 15.1% was deintensified. Of 25 955 patients with moderately low BP levels, treatment in 16.0% was deintensified. Among 81 226 patients with very low BP levels, 18.8% underwent BP medication deintensification. Of patients with very low BP levels whose treatment was not deintensified, only 0.2% had a follow-up BP measurement that was elevated (BP Ն140/90 mm Hg). The actively treated HbA 1c cohort included 179 991 participants. Of 143 305 patients with HbA 1c levels that were not low, treatment in 17.5% was deintensified. Of 23 769 patients with moderately low HbA 1c levels, treatment in 20.9% was deintensified. Among 12 917 patients with very low HbA 1c levels, 27.0% underwent medication deintensification. Of patients with very low HbA 1c levels whose treatment was not deintensified, fewer than 0.8% had a follow-up HbA 1c measurement that was elevated (Ն7.5%). CONCLUSIONS AND RELEVANCE Among older patients whose treatment resulted in very low levels of HbA 1c or BP, 27% or fewer underwent deintensification, representing a lost opportunity to reduce overtreatment. Low HbA 1c or BP values or low life expectancy had little association with deintensification events. Practice guidelines and performance measures should place more focus on reducing ove...

IMPORTANCE Evidence comparing the consequences of Choosing Wisely recommendations across health systems or with the consequences of recommendations plus policy change is lacking.OBJECTIVES To compare changes in the use of 2 low-value laboratory tests after the release of Choosing Wisely recommendations across 3 health care jurisdictions and changes associated with a related policy change. DESIGN, SETTING, AND PARTICIPANTSThis cross-sectional study was a population-based interrupted time series of adult patients (aged 18-64 years) who had primary care visits

Objective Examine the association between sedentary behavior and psychiatric symptoms among overweight and obese adults with schizophrenia or schizoaffective disorders (SZO/SA). Design Randomized clinical trial; Weight Assessment and Intervention in Schizophrenia Treatment (WAIST) Study: baseline data collected 2005-2008. Setting University of Pittsburgh Medical Center, Pittsburgh, PA, USA Participants Community-dwelling adults diagnosed with SZO/SA, with mild symptom severity [Positive and Negative Syndrome Scale (PANSS)<90], who were interested in losing weight, age 18-70 years, BMI>27 kg/m2. Measurements Objectively measured sedentary behavior by accelerometry, and psychopathology assessed by PANSS. Participants wore the actigraphs for 7 consecutive days during their waking hours. Sedentary behavior was defined as ≤100 counts per minute during wear-time and excluded sleep and non-wear time. Results On average, 81% of the participant’s monitoring time or 756 mins/day was classified as sedentary behavior using accelerometry. No association was observed between sedentary behaviors and PANSS psychiatric symptoms [total (p≥0.75), positive (p≥0.81), negative (p≥0.59) and general psychopathology (p≥0.65) subscales]. No association was observed between sedentary behaviors and age, race, gender and BMI. Conclusion From a clinical and public health perspective, the amount of time (approximately 13 hours) and percentage of time (81% excluding non-wear time associated with sleeping) engaged in sedentary behavior among overweight and obese adults in this population is alarming, and points to an urgent need for interventions to decrease sedentary behaviors. The lack of associations between sedentary behavior and psychiatric symptoms may be due to a ceiling effect for sedentary behavior.