No conflicts of interest

1. No conflicts of interest

2. Please ask questions

3. DukeProSPER.org

4. Adaptive coping after critical illness: a novel mobile patient-centered interventionChristopher CoxDuke University Pulmonary, Critical Care, and Palliative Medicine

5. Mike: 48yo with ARDS from pneumonia. Gets home—weak, PTSD. Why am I like this?

6. Patient-centered care…dimensions & concepts Open information access Collaborative management Family & friends involved Non-medical & spiritual needs Respect for patient preferences Physical / emotional symptoms 1 Balint 1969 Picker Institute/Commonwealth 1993 Curtis, Rubenfeld, Angus, Herridge, Needham, Carson, Hopkins PCORI 2011

7. Patient-centered care…dimensions & concepts information access collaborative management family & friends involved non-medical & spiritual needs respect for patient preferences physical / emotional symptoms 1 2 Balint 1969 Picker Institute/Commonwealth 1993 Curtis, Rubenfeld, Angus, Herridge, Needham, Carson, Hopkins PCORI 2011

8. Challenges of patient-centered outcomes Define, prioritize, measure, ask? How to engage patients in research? When you have a hammer…aligning patient interests & research capacityPatient – provider translator? Gabriel SE 2012

9. Past and current: the impact of critical illness isprofound and persistent Herridge, Stelling, Covinsky, Carson, Nelson, Cox, Bienvenu, Needham, 1990s-2000s

10. Psychological distress symptoms are serious among ICU survivors Distress = depression, anxiety, PTSD 40% saw a mental health provider 50% using psych meds after discharge Many patients describe in their own words: “People sometimes do not know what you go through. They think that because you are in one piece, everything is fine. But inside I’m all screwed up now.” Weinert 2006; Cox 2009; Bienvenu 2013

11. Psychological distress: difficult to prevent, complicated to treat Delusional memories Comorbidities & psych history Treatment (sedation, PaO2, glucose) Social support Caregiving needs Illness severity Symptoms Cognition Communication Davydow 2011, Azoulay 2005, Bienvenu 2013

12. Trajectories of post-discharge health are complicated and tough to predict cancer chemo health status septic shock

13. Trajectories of post-discharge health are complicated and tough to predict depression, anxiety, PTSD cancer chemo septic shock

14. And other challenges… Heterogeneous patients Very disabled—hard to return to clinic Logistical challenges Transient and permanent disability Few targeted therapies Gabriel SE 2012

15. How can I get my life back?

16. Study 1 critical illness defining sense of self patient-family relationship strain pervasive traumatic memories inability to cope with new disability day to day impact of critical illness Cox 2009

17. What is coping: thoughts and actions used to manage stress…not a passive process

18. Conceptual model of coping & distress

19. Study 2:Poor coping ability is common among ICU survivors Cox, Porter, Keefe, et al. 2012

20. Study 2: Maladaptive coping is correlated with psychological distress & QOL Cox, Porter, Keefe, et al. 2012

21. Study 3: Can we develop a coping skills intervention that is feasible, acceptable, and shows promise?

22. Study 3: Can we develop a coping skills intervention that is feasible, acceptable, and shows promise? Cox, Porter, Keefe, et al. 2012

23. Study 3: Individualization, self-management, collaborative care Cox, White, Carson, Hough, Kahn, Porter, Keefe 2012

24. Study 3: Coping skills intervention elements for specific distress targets

25. How does coping training work in practice? Mrs. Edwards says main stressor is post-ICU physical disability. She also has troubling memories of the ICU. Session 1 starts with activity-rest cycling, focusing on activities of daily living that she values. She reviews the material in the guidebook and discusses it with her daughter. At Session 2, she is more confident in her ability to manage distress. The next topic most relevant to her distress about troubling memories is begun (cognitive restructuring). This strategy of personalization, self-management, and feedback continues through other phone sessions.

26. Study 3: Coping skills training may reduce distress Cox, Porter, Keefe, et al. 2012

27. Study 3: Conceptual model validated: distress reduction correlates with enhanced self-efficacy & adaptive coping Cox, Porter, Keefe, et al. 2012

28. Study 3: Evaluation: coping skills program feasible & acceptable

29. Current RCT: adaptive coping skills vs. education programs by phone & web

31. I can get back on track faster

32. PS: challenges of patient-centered outcomes Define, prioritize, measure, ask? How to engage patients in research? When you have a hammer…aligning patient interests & research capacityPatient – provider translator? Gabriel SE 2012

33. What about the future of this and similar interventions? Choice & precision: Preference- and needs-based, individualizable treatment. Self-management: Self-pacing, logic-based content, non-professional interventionists, and feedback on effect Convenience & mobility: Balancing people (human but more expensive) with mobile devices (cheap, high tech, widely used).

34. Future?

35. Summary: coping skills training to reduce distress using patient-centered methodology

36. DukeProSPER.org

37. Questions for tech support? THANKS!