Search

Study design:Multi-center, prospective, cohort study.Objectives:To assess the validity and reliability of the Spinal Cord Independence Measure (SCIM III) in measuring functional ability in persons with spinal cord injury (SCI).Setting:Inpatient rehabilitation hospitals in the United States (US).Methods:Functional ability was measured with the SCIM III during the first week of admittance into inpatient acute rehabilitation and within one week of discharge from the same rehabilitation program. Motor and sensory neurologic impairment was measured with the American Spinal Injury Association Impairment Scale. The Functional Independence Measure (FIM), the default functional measure currently used in most US hospitals, was used as a comparison standard for the SCIM III. Statistical analyses were used to test the validity and reliability of the SCIM III.Results:Total agreement between raters was above 70% on most SCIM III tasks and all κ-coefficients were statistically significant (P<0.001). The coefficients of Pearson correlation between the paired raters were above 0.81 and intraclass correlation coefficients were above 0.81. Cronbach's-α was above 0.7, with the exception of the respiration task. The coefficient of Pearson correlation between the FIM and SCIM III was 0.8 (P<0.001). For the respiration and sphincter management subscale, the SCIM III was more responsive to change, than the FIM (P<0.0001).Conclusion:Overall, the SCIM III is a reliable and valid measure of functional change in SCI. However, improved scoring instructions and a few modifications to the scoring categories may reduce variability between raters and enhance clinical utility. [ABSTRACT FROM AUTHOR]

Background: Place-based international electives that build global health competencies have existed for decades. However, these electives require travel and are infeasible for many trainees around the world, particularly those with insufficient financial resources, logistical complexities, or visa limitations. The emergence of virtual approaches to global health electives, catalyzed by the travel pause related to the COVID-19 pandemic, necessitates the exploration of learner impacts, participant diversity, and curricular frameworks. Child Family Health International (CFHI), a non-profit global health education organization that partners with universities to expand immersive educational offerings, launched a virtual global health elective in 2021. The elective drew on faculty from Bolivia, Ecuador, Ghana, Mexico, the Philippines, Uganda, and the United States., Objective: This study aimed to describe a newly developed virtual global health elective curriculum and evaluate the demographics of and impacts on trainee participants., Methods: Eighty-two trainees who were enrolled in the virtual global health elective from January to May 2021 completed both 1) pre- and post-elective self-assessments of domains of competency mapped to the elective curriculum and 2) free text responses to standardized questions. Data were analyzed through descriptive statistical analysis, paired t-testing, and qualitative thematic analysis., Findings: The virtual global health elective had 40% of its participants hail from countries other than the United States. Self-reported competency in global health broadly, planetary health, low resource clinical reasoning, and overall composite competency significantly increased. Qualitative analysis revealed learner development in health systems, social determinants of health, critical thinking, planetary health, cultural humility, and professional practice., Conclusion: Virtual global health electives effectively develop key competencies in global health. This virtual elective had a 40-fold increase in the proportion of trainees from outside the United States, compared to pre-pandemic place-based electives. The virtual platform facilitates accessibility for learners from a variety of health professions and a wide range of geographic and socioeconomic environments. Further research is needed to confirm and expand on self-reported data, and to pursue approaches to greater diversity, equity, and inclusion in virtual frameworks., Competing Interests: The authors have no competing interests to declare., (Copyright: © 2023 The Author(s).)

Introduction: Rural and under-resourced urban communities face unique challenges in addressing patients' social determinants of health needs (SDoH). Community health workers (CHWs) can support patients experiencing social needs, yet little is known about how rural and under-resourced primary care clinics are screening for SDoH or utilizing CHWs., Methods: Interviews were conducted with primary care clinic providers and managers across a geographically large and predominately rural state to assess screening practices for SDoH and related community resources, and perspectives on using CHWs to address SDoH. Interviews were conducted by phone, recorded, and transcribed. Data were analyzed using thematic analysis. We completed interviews with 27 respondents (12 providers and 15 clinic managers) at 26 clinics., Results: Twelve (46.1%) clinics had a standardized process for capturing SDoH, but this was primarily limited to Medicare wellness visits. Staffing and time were identified as barriers to proper SDoH screening. Lack of transportation and affordable medication were the most cited SDoH. While respondents were all aware of CHWs, only 8 (30.8%) included a CHW on their care team. Perceived barriers to engaging CHWs included cost, space, and availability of qualified CHWs. Perceived benefits of engaging CHWs in their practice were: assisting patients with navigating resources and programs, relieving clinical staff of non-medical tasks, and bridging language barriers., Conclusions: Rural and under-resourced primary care clinics need help in identifying and addressing SDoH. CHWs could play an important part in addressing social needs and promoting preventive care if financial constraints could be addressed and local CHWs could be trained., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

BACKGROUND: Medication therapy management (MTM) and comprehensive medication management (CMM) have been practiced by clinical pharmacists as a predominantly manual activity with interventions documented in a record-keeping system. Program evaluations, largely based on estimations of projected savings and utilization reductions, have not accurately predicted actual claims and utilization changes, leading many to doubt the efficacy of medication management. OBJECTIVE: To assess the impact on actual medical claims of a novel artificial intelligence (AI) platform that identifies members and provides decision support to clinicians in performing telephonic interventions similar to MTM and CMM with high-risk Medicaid members. METHODS: This retrospective observational study used mixed-effects regression models that flexibly account for general trends in cost, as measured by actual claims, to identify the amount of savings and associated impact. To study the economics, total cost of care (TCoC), defined as all medication costs plus all noncapitated medical costs, was evaluated. Utilization was evaluated through the number of emergency department (ED) visits, hospital admissions, bed days, and readmissions. The study included 2,150 predominantly middle-aged (aged 40-64 years) Medicaid members with an average of 10 medications for chronic conditions among an average of 25 total medications. The analysis considered cost and utilization data from August 2017 through April 2019. Interventions occurred between January 2018 and February 2019. RESULTS: Statistically significant correlations were found between receiving interventions and decreased costs and utilization. The economic study found a 19.3% reduction in the TCoC ( P < 0.001) that, applied to a preintervention monthly cost of $2,872, yielded a savings of $554 per member per month (PMPM). Medication costs showed a 17.4% reduction ( P < 0.001), which, when applied to preintervention cost of $1,110, yielded a savings of $192 PMPM. The utilization study found a 15.1% reduction in ED visits ( P = 0.002), a 9.4% reduction in hospital admissions ( P = 0.008), and a 10.2% reduction in bed days ( P = 0.01). Return on investment is 12.4:1 based on TCoC savings and program costs. CONCLUSIONS: This study evaluated the CMM-Wrap program, which used an advanced AI platform integrated with health plan data, clinical pharmacists trained in disease management, telephonic patient engagement, and closed-loop provider coordination. The results correlate cost and utilization savings with the program. The TCoC savings of $554 PMPM translates to approximately $1.2M a month and more than $14M annually for the 2,150 members in the study. We believe Medicaid and Medicare payment of AI enhanced telephonic CMM services would substantially decrease government health care expenditures, whereas improving health program expansion to Medicaid members with similar risks could save the Health Plan $109M annually. For instance, we estimate that California's Medicaid (Medi-Cal) program could save more than $1B annually by applying the program's observed impact to a similar high-risk cohort (about 1.6%) of Medi-Cal members. Additionally, benefits will accrue to nonmanaged health plans based on the savings themselves. DISCLOSURES : There was no external funding for this study. The program itself was funded by Inland Empire Health Plan. The retrospective study was a collaboration of the 3 partners (Surveyor Health, Inland Empire Health Plan, and Preveon Health) each of which funded its additional costs of preparing the study. Kessler, Mebine, E. Von Schweber, and L. Von Schweber are employed by Surveyor Health. McConnell and Jai are employed by Inland Empire Health Plan. Nguyen, Kiroyan, and Ho are employed by Preveon Health. Desai reports fees from Surveyor Health for work on this study. E. Von Schweber and L. Von Schweber have 2 patents licensed to Surveyor Health: Unified Evaluation, Presentation and Modification of Healthcare Regimens Method and Apparatus for Information Surveying.

Background: The sharp rise in opioid use disorder (OUD) among women coupled with disproportionally high rates of unintended pregnancy have led to a four-fold increase in the number of pregnant women with OUD in the United States over the past decade. Supporting intentional family planning can have multiple health benefits and reduce harms related to OUD but requires a comprehensive understanding of women's perspectives of preventing unintended pregnancies. The purpose of this study was to comprehensively evaluate the knowledge, attitudes and experiences as they relate to seeking contraception, particularly LARCs, among women with active or recovered opioid misuse., Methods: In-depth interviews and focus group discussions with 36 women with current or past opioid misuse were recorded and transcribed. Transcripts were coded by ≥ 2 investigators. Themes related to contraceptive care seeking were identified and contextualized within the Health Belief Model., Results: Our analysis revealed seven interwoven themes that describe individual level factors associated with contraceptive care seeking in women with current or past opioid misuse: relationship with drugs, reproductive experiences and self-perceptions, sexual partner dynamics, access, awareness of options, healthcare attitudes/experiences, and perceptions of contraception efficacy/ side effects. Overall, perceived susceptibility and severity to unintended pregnancy varied, but most women perceived high benefits of contraception, particularly LARC. However, perceived barriers were too high for most to obtain desired contraception to support family planning intentions., Conclusions: The individual-level factors identified should inform the design of integrated services to promote patient-centered contraceptive counseling as a form of harm reduction. Interventions should reduce barriers to contraceptive access, particularly LARCs, and establish counseling strategies that use open, non-judgmental communication, acknowledge the continuum of reproductive needs, explore perceived susceptibility to pregnancy, and utilize peer educators., (© 2021. The Author(s).)

Preconception care is an essential component of health, particularly among women and men living with HIV and can optimize medical and psychosocial outcomes. However, there is a paucity of data on this topic, especially when evaluating provider communication with male patients. We conducted a multi-site qualitative study in 7 cities in the United States (US) with 92 providers to assess their attitudes and practices regarding preconceptual counseling, safer conception, and preconception care with their patients living with HIV. Providers were contacted to schedule a phone interview. Recorded interviews were transcribed and coded for a priori and emergent themes. Providers reported infrequent communication with male patients with HIV about their reproductive plans and the use of safer conception, acknowledging they were more likely to initiate such communication with female patients. A small percentage of providers reported talking to all of their patients about reproductive options, including men having sex with men (MSM). Currently, there is no consensus or evidence-based guideline for the delivery of preconception care specific to men. Based on our results, we recommend that providers offer preconception care to all men as part of optimizing family planning and pregnancy outcomes; enhancing reproductive health; preparing men for fatherhood; and in the setting of HIV infection, preventing transmission to an uninfected partner.

Background: In 2000, the Food and Drug Administration (FDA) approved gemtuzumab ozogamycin for monotherapy for older patients with relapsed AML. A 0.9% rate of hepatic sinusoidal obstructive syndrome (SOS) was noted in licensing trials. In 2001, FDA received reports of 14 GO-associated SOS cases from MD Anderson Cancer Center. A State of South Carolina/National Cancer Institute funded pharmacovigilance program and a manufacturer sponsored registry independently evaluated this concern., Methods: The manufacturer's registry and the academic program focused on risk factors and incidence of GO-associated SOS in routine clinical practice and clinical trial settings, respectively. Comparisons were made of findings and dissemination efforts from the two studies., Results: Retrospective analysis of clinical trials by the academic initiative identified 99 cases of SOS among 221 GO-treated stem cell patients and 649 patients who did not undergo HSCTs. SOS rates were 3% when GO was administered at doses ≤6 mg/m(2) as monotherapy or with non-hepatotoxic agents; 28% when administered with 6-thioguanine, a hepatotoxic agent; 15% when administered as monotherapy at doses at a dose of 9 mg/m(2), and between 15% and 40% if a stem cell transplant (SCT) was performed within 3 months of GO administration. Death from SOS occurred in 33% of the cases. The manufacturer's registry prospectively evaluated 482 GO-treated patients who received a mean dose of 7.8 mg/m(2). Overall, 41% received concomitant chemotherapy, 18% had undergone prior SCT, 9.1% developed SOS, and death from SOS occurred in 60% of the SOS cases. Findings from each initiative were disseminated at national conferences and in peer-reviewed manuscripts beginning in 2003., Conclusion: Retrospective review of clinical trials, case series, and FDA reports and prospective registries can provide important information on safety signals initially identified in licensing trials., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Multistate outbreaks of salmonellosis associated with live poultry contact have been occurring with increasing frequency. In 2013, multistate outbreaks of salmonellosis were traced back to exposure to live poultry, some of which were purchased at a national chain of farm stores (Farm store chain Y). This study was conducted at 36 stores of Farm store chain Y and was concurrent with the timing of exposure for the human outbreaks of salmonellosis in 2013. We used environmental swabs of arriving shipment boxes of hatchling poultry and shipment tracking information to examine the distribution, diversity and anti-microbial resistance of non-typhoidal Salmonella (NTS) across farm stores and hatcheries. Isolates recovered from shipment boxes underwent serotyping, anti-microbial resistance (AMR) testing and pulsed-field gel electrophoresis (PFGE). Postal service tracking codes from the shipment boxes were used to determine the hatchery of origin. The PFGE patterns were compared with the PFGE patterns of NTS causing outbreaks of salmonellosis in 2013. A total of 219 hatchling boxes from 36 stores in 13 states were swabbed between 15 March 2013 and 18 April 2013. NTS were recovered from 59 (27%) of 219 hatchling boxes. Recovery was not significantly associated with species of hatchlings, number of birds in the shipment box, or the presence of dead, injured or sick birds. Four of the 23 PFGE patterns and 23 of 50 isolates were indistinguishable from strains causing human outbreaks in 2013. For serotypes associated with human illnesses, PFGE patterns most frequently recovered from shipment boxes were also more frequent causes of human illness. Boxes positive for the same PFGE pattern most frequently originated from the same mail-order hatchery. Only one of 59 isolates was resistant to anti-microbials used to treat Salmonella infections in people. This study provides critical information to address recurrent human outbreaks of salmonellosis associated with mail-order hatchling poultry., (© 2014 Blackwell Verlag GmbH.)

Although a significant number of HIV-positive women intend to have children in the future, few work with providers to safely plan pregnancy. We conducted 20 semistructured in depth interviews with HIV-positive adolescent and adult women receiving HIV clinical care in an urban setting. Participants were purposively sampled to include diversity in age and childbearing plans. Interview transcripts were analyzed and coded independently by two study team members before reaching consensus on emergent themes. Among this sample of HIV-positive women (mean age=27.9, 95% African American, 50% on antiretroviral therapy [ART], 65% want a biological child), only 25% reported discussing their childbearing goals with their HIV provider. Women actively trying to conceive recognized the risk to themselves and their partner, but had not talked with their provider about safer conception strategies. Data regarding provider communication about childbearing were organized by the following emergent themes: (1) confusion and concern on how to conceive safely, (2) provider characteristics or dynamics that influenced communication, and (3) provider guidance offered regarding childbearing. Even in this unique study setting in which referrals for preconception counseling are possible, women were unaware of this specialized service. Provider initiated reproductive counseling is needed to strategically avoid or plan pregnancy and reduce risk of transmission to partners and infants rather than leaving it to chance, which can have major health implications.

Objective: Few articles have examined specific counseling tools used to increase antiretroviral therapy (ART) adherence. We present communication tools used in the context of Project MOTIV8, a randomized clinical trial., Methods: We developed, piloted, and evaluated pictorial images to communicate the importance of consistent dose timing and the concept of drug resistance. Electronic drug monitoring (EDM) review was also used to provide visual feedback and facilitate problem solving discussions. Adherence knowledge of all participants (n=204) was assessed at baseline and 48 weeks. Participant satisfaction with counseling was also assessed., Results: Adherence knowledge did not differ at baseline, however, at 48 weeks, intervention participants demonstrated significantly increased knowledge compared to controls F(1, 172)=10.76, p=0.001 (12.4% increase among intervention participants and 1.8% decrease among controls). Counselors reported that the tools were well-received, and 80% of participants felt the counseling helped them adhere to their medications., Conclusions: Counseling tools were both positively received and effective in increasing ART adherence knowledge among a diverse population., Practice Implications: While developed for research, these counseling tools can be implemented into clinical practice to help patients; particularly those with lower levels of education or limited abstract thinking skills to understand medical concepts related to ART adherence., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

To assess childbearing motivations, fertility desires and intentions, and their relationship with key factors, we conducted a cross-sectional survey among 181 HIV-infected women of reproductive age (15-44 years) receiving clinical care at two urban health clinics. Fertility desires (59%) and intentions (66% of those who desired a child) were high among this predominately African American sample of women, while the proportion with accurate knowledge of mother-to-child transmission (MTCT) was low (15%). Multivariate regression analyses identified factors significantly associated with the intention to have a child. Notably, age and parity did not remain significant in the adjusted model. The discrepancies between expressed desires and intentions for future childbearing, and the strong role of perceived partner desire for childbearing emphasize the need for universal reproductive counseling to help women living with HIV navigate their reproductive decisions and facilitate safe pregnancies and healthy children.

The focus of our CQI Investigation was to determine whether home telehealth is the "Silver Bullet" in reducing re-hospitalizations, managing visits per episode, implementing disease management strategies, and improving patient satisfaction. In this article, we will discuss the challenges of developing and implementing a telehealth program in a free standing non-profit agency, the program design and its components, and obstacles encountered including those presented by home care staff and area physicians. When we started this project, we had no idea what the results would be. There were some surprises along the way.