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Background: Emergency department visits and rehospitalization are common after hospital discharge.Objective: To test the effects of an intervention designed to minimize hospital utilization after discharge.Design: Randomized trial using block randomization of 6 and 8. Randomly arranged index cards were placed in opaque envelopes labeled consecutively with study numbers, and participants were assigned a study group by revealing the index card.Setting: General medical service at an urban, academic, safety-net hospital.Patients: 749 English-speaking hospitalized adults (mean age, 49.9 years).Intervention: A nurse discharge advocate worked with patients during their hospital stay to arrange follow-up appointments, confirm medication reconciliation, and conduct patient education with an individualized instruction booklet that was sent to their primary care provider. A clinical pharmacist called patients 2 to 4 days after discharge to reinforce the discharge plan and review medications. Participants and providers were not blinded to treatment assignment.Measurements: Primary outcomes were emergency department visits and hospitalizations within 30 days of discharge. Secondary outcomes were self-reported preparedness for discharge and frequency of primary care providers' follow-up within 30 days of discharge. Research staff doing follow-up were blinded to study group assignment.Results: Participants in the intervention group (n = 370) had a lower rate of hospital utilization than those receiving usual care (n = 368) (0.314 vs. 0.451 visit per person per month; incidence rate ratio, 0.695 [95% CI, 0.515 to 0.937]; P = 0.009). The intervention was most effective among participants with hospital utilization in the 6 months before index admission (P = 0.014). Adverse events were not assessed; these data were collected but are still being analyzed.Limitation: This was a single-center study in which not all potentially eligible patients could be enrolled, and outcome assessment sometimes relied on participant report.Conclusion: A package of discharge services reduced hospital utilization within 30 days of discharge.Funding: Agency for Healthcare Research and Quality and National Heart, Lung, and Blood Institute, National Institutes of Health. [ABSTRACT FROM AUTHOR]

Objective: To estimate the prevalence and length of gaps in health insurance coverage and their effect on having a regular source of care in a national sample of preschool-aged children.Design: Follow-up survey of a nationally representative sample of 3-year-old children in the US population by phone or personal interview.Participants: A total of 8129 children whose mothers were interviewed for the 1991 longitudinal Follow-up to the National Maternal and infant Health Survey.Main Outcome Measures: Report of any gap in health insurance for the children, the length of the gap, and the number of different sites where the children were taken for medical care as a measure of continuity of a regular source of care.Results: About one quarter of Us children were without health insurance for at least 1 month during their first 3 years of life. Over half of these children had a health insurance gap of more than 6 months. Less than half of US children had only one site of care during their first 3 years. Children with health insurance gaps of longer than 6 months were at increased risk of having more than one care site (odds ratio = 1.52; 95% confidence interval, 1.19 to 1.96). This risk further increased when an emergency treatment was discounted as a multiple site of care.Conclusions: Having a gap in health insurance coverage is an important determinant for not having a regular source of care for preschool-aged children. This finding is of concern, given the sizable percentage of children in the United States who lacked continuous health care coverage during a critical period of development. [ABSTRACT FROM AUTHOR]

The Public Health Service's Expert Panel on the Content of Prenatal Care Report in 1989 provided detailed guidelines for the components of each prenatal visit. However, the extent to which women were receiving the recommended care when the guidelines were being formulated has yet to be determined. The 1988 National Maternal and Infant Health Survey results permit an examination of the proportion of women who reported receiving some of the recommended procedures. Women were asked if they received six of the recommended procedures (blood pressure measurement, urine test, blood test, weight and height taken, pelvic examination, and pregnancy history) in the first two visits, and whether they received seven types of advice or counseling (nutrition; vitamin use; smoking, alcohol, and drug use cessation; breastfeeding; and maternal weight gain) any time during their pregnancy. Only 56 percent of the respondents said they received all of the recommended procedures in the first two visits, and only 32 percent of the respondents said they received advice in all of the areas. Logistic regression analysis indicated that women receiving their care from private offices were significantly less likely to receive all the procedures and advice than women at publicly funded sites of care. This study suggests that recommendations of the Public Health Service's expert panel were not being met. [ABSTRACT FROM AUTHOR]

Objective: To assess whether site of prenatal care influences the content of prenatal care for low-income women. Design. Bivariate and logistic analyses of prenatal care content for low-income women provided at five different types of care sites (private offices, HMOs, publicly funded clinics, hospital clinics, and other sites of care), controlling for sociodemographic, behavioral, and maternal health characteristics. Participants: A sample of 3405 low-income women selected from a nationally representative sample of 9953 women surveyed by the National Maternal and Infant Health Survey, who had singleton live births in 1988, had some prenatal care (PNC), Medicaid participation, or a family income less than $12,000/year. Outcome Measures: Maternal report of seven initial PNC procedures (individually and combined), six areas of PNC advice (individually and combined), and participation in the Women Infant Children (WIC) nutrition program. Results: The content of PNC provided for low-income women does nor meet the recommendations of the U.S. Public Health Service, and varies by site of delivery. Low-income women in publicly funded clinics (health departments and community health centers) report receiving more total initial PNC procedures and total PNC advice and have greater participation in the WIC program than similar women receiving PNC in private offices. Conclusions: Publicly funded sites of care appear to provide more comprehensive prenatal care services than private office settings. Health care systems reforms which assume equality of care across all sites, or which limit services to restricted sites, may foster unequal access to comprehensive PNC. [ABSTRACT FROM AUTHOR]

Women of child-bearing age should achieve and maintain good nutritional status prior to conception to help minimize health risks to both mothers and infants. Many women may not be aware of the importance of preconception nutrition and supplementation or have access to nutrition information. Health care providers should be knowledgeable about preconception/pregnancy-related nutrition and take the initiative to discuss this information during preconception counseling. Women of reproductive age should be counseled to consume a well-balanced diet including fruits and vegetables, iron and calcium-rich foods, and protein-containing foods as well as 400 microg of folic acid daily. More research is critically needed on the efficacy and safety of dietary supplements and the role of obesity in birth outcomes. Preconception counseling is the perfect opportunity for the health care provider to discuss a healthy eating guideline, dietary supplement intake, and maintaining a healthy weight status. [ABSTRACT FROM AUTHOR]

Background: The management of type 2 diabetes mellitus (T2DM) includes mastery of complex care activities, self-management skills, and routine health care encounters to optimize glucose control and achieve good health. Given the lifelong course of T2DM, patients are faced with navigating complex medical and disease-specific information. This health-seeking behavior is a driver of health disparities and is associated with hospitalization and readmission. Given that health-seeking behavior is a potentially intervenable social determinant of health, a better understanding of how people navigate these complex systems is warranted., Objective: To address this need, we aimed to develop new patient-reported outcome (PRO) measures that evaluate health-seeking behavior in persons with T2DM. These new PROs were designed to be included in the Re-Engineered Discharge for Diabetes-Computer Adaptive Test (REDD-CAT) measurement system, which includes several other PROs that capture the importance of social determinants of health., Methods: Overall, 225 participants with T2DM completed 56 self-report items that examined health-seeking behaviors. Classical Test Theory and Item Response Theory were used for measurement development. Exploratory factor analysis (EFA; criterion ratio of eigenvalue 1 to eigenvalue 2 being >4; variance for eigenvalue 1 ≥40%) and confirmatory factor analysis (CFA; criterion 1-factor CFA loading <.50; 1-factor CFA residual correlation >.20; comparative fit index ≥0.90; Tucker-Lewis index ≥0.90; root mean square error of approximation <0.15) were used to determine unidimensional sets of items. Items with sparse responses, low-adjusted total score correlations, nonmonotonicity, low factor loading, and high residual correlations of high error modification indices were candidates for exclusion. A constrained graded response model was used to examine item misfit, and differential item functioning was examined to identify item bias. Cronbach α was used to examine internal consistency reliability for the new PROs (criterion ≥0.70), and floor and ceiling effects were examined (criterion ≤20%)., Results: Four unidimensional sets of items were supported by EFA (all EFA eigenvalue ratios >4; variance for eigenvalue 1=41.4%-67.3%) and CFA (fit statistics all exceeded criterion values). This included (1) "Health-Seeking Behavior: PCP-Specific" (6 items); (2) "Health-Seeking Behavior: General Beliefs" (13 items); (3) "Health-Seeking Behavior: Family or Friends-Specific" (5 items); and (4) "Health-Seeking Behavior: Internet-Specific" (4 items). All items were devoid of differential item functioning for age, sex, education, or socioeconomic status factors. "Health-Seeking Behavior: General Beliefs" was developed to include both a computer adaptive test and a 6-item short form version; all other PROs were developed as static short forms. The psychometric reliability of these new PROs was supported; internal consistency ranged from acceptable to excellent (Cronbach α=.78-.91), and measures were free of significant floor or ceiling effects (floor effects range: 0%-8.9%; ceiling effects range: 0%-8.4%)., Conclusions: The new REDD-CAT Health-Seeking Behavior PROs provide reliable assessments of health-seeking behaviors among those with T2DM., (©Suzanne E Mitchell, Michael A Kallen, Jonathan P Troost, Barbara A De La Cruz, Alexa Bragg, Jessica Martin-Howard, Ioana Moldovan, Jennifer A Miner, Brian W Jack, Noelle E Carlozzi. Originally published in JMIR Diabetes (https://diabetes.jmir.org), 22.11.2024.)

Background: Young women in Lesotho face myriad sexual and reproductive health problems. There is little time to provide health education to women in low-resource settings with critical shortages of human resources for health., Objective: This study aims to determine the acceptability and usability of a conversational agent system, the Nthabi health promotion app, which was culturally adapted for use in Lesotho., Methods: We conducted a descriptive quantitative study, using a 22-item Likert scale survey to assess the perceptions of the usability and acceptability of 172 young women aged 18-28 years in rural districts of Lesotho, who used the system on either smartphones or tablets for up to 6 weeks. Descriptive statistics were used to calculate the averages and frequencies of the variables. χ 2 tests were used to determine any associations among variables., Results: A total of 138 participants were enrolled and completed the survey. The mean age was 22 years, most were unmarried, 56 (40.6%) participants had completed high school, 39 (28.3%) participants were unemployed, and 88 (63.8%) participants were students. Respondents believed the app was helpful, with 134 (97.1%) participants strongly agreeing or agreeing that the app was "effective in helping them make decisions" and "could quickly improve health education and counselling." In addition, 136 (98.5%) participants strongly agreed or agreed that the app was "simple to use," 130 (94.2 %) participants reported that Nthabi could "easily repeat words that were not well understood," and 128 (92.7%) participants reported that the app "could quickly load the information on the screen." Respondents were generally satisfied with the app, with 132 (95.6%) participants strongly agreeing or agreeing that the health education content delivered by the app was "well organised and delivered in a timely way," while 133 (96.4%) participants "enjoyed using the interface." They were satisfied with the cultural adaptation, with 133 (96.4%) participants strongly agreeing or agreeing that the app was "culturally appropriate and that it could be easily shared with a family or community members." They also reported that Nthabi was worthwhile, with 127 (92%) participants reporting that they strongly agreed or agreed that they were "satisfied with the application and intended to continue using it," while 135 (97.8%) participants would "encourage others to use it." Participants aged 18-24 years (vs those aged 25-28 years) agreed that the "Nthabi app was simple to use" (106/106, 100% vs 30/32, 98.8%; P=.01), and agreed that "the educational content was well organised and delivered in a timely way" (104/106, 98.1% vs 28/32, 87.5%; P=.01)., Conclusions: These results support further study of conversational agent systems as alternatives to traditional face-to-face provision of health education services in Lesotho, where there are critical shortages of human resources for health., Trial Registration: ClinicalTrials.gov NCT04354168; https://www.clinicaltrials.gov/study/NCT04354168., (©Elizabeth Nkabane-Nkholongo, Mathildah Mpata-Mokgatle, Brian W Jack, Clevanne Julce, Timothy Bickmore. Originally published in JMIR Human Factors (https://humanfactors.jmir.org), 12.03.2024.)

Background: Public-private partnerships (PPP) are one strategy to finance and deliver healthcare in lower-resourced settings. Lesotho's Queen 'Mamohato Memorial Hospital Integrated Network (QMMH-IN) was sub-Saharan Africa's first and largest integrated healthcare PPP., Objective: We assessed successes and challenges to performance of the QMMH-IN PPP., Methods: We conducted 26 semi-structured interviews among QMMH-IN executive leadership and staff in early 2020. Questions were guided by the WHO Health System Building Blocks Framework. We conducted a thematic analysis., Findings: Facilitators of performance included: 1) PPP leadership commitment to quality improvement supported by protocols, monitoring, and actions; 2) high levels of accountability and discipline; and 3) well-functioning infrastructure, core systems, workflows, and internal referral network. Barriers to performance included: 1) human resource management challenges and 2) broader health system and referral network limitations. Respondents anticipated the collapse of the PPP and suggested better investing in training incoming managerial staff, improving staffing, and expanding QMMH-IN's role as a training facility., Conclusions: The PPP contract was terminated approximately five years before its anticipated end date; in mid-2021 the government of Lesotho assumed management of QMMH-IN. Going forward, the Lesotho government and others making strategic planning decisions should consider fostering a culture of quality improvement and accountability; ensuring sustained investments in human resource management; and allocating resources in a way that recognizes the interdependency of healthcare facilities and overall system strengthening. Contracts for integrated healthcare PPPs should be flexible to respond to changing external conditions and include provisions to invest in people as substantively as infrastructure, equipment, and core systems over the full length of the PPP. Healthcare PPPs, especially in lower-resource settings, should be developed with a strong understanding of their role in the broader health system and be implemented in conjunction with efforts to ensure and sustain adequate capacity and resources throughout the health system., Competing Interests: The authors have no competing interests to declare., (Copyright: © 2024 The Author(s).)

Background:  Since 2020, the world has been battling the coronavirus disease 2019 (COVID-19) pandemic. The mortality and morbidity at the height of the pandemic sparked generalised fear and uncertainty about the future. Concerns were raised about the psychological impact of the pandemic on workers in healthcare systems globally. This study was conducted to establish the degree of psychological impact of the pandemic on frontline health workers in Lesotho., Methods:  The study used a quantitative cross-sectional survey design. The Kessler psychological distress screening tool (K-10) and the post-traumatic stress disorder (PTSD) checklist for civilians (PCL-C) were administered to screen for psychological distress among clinical staff at St. Joseph's Hospital in Roma and its four Health Centres. Additional open- and closed-ended questions were added for context. Data were analysed using Fisher's exact tests, Pearson chi-square tests and correlation studies., Results:  Of the 101 participants, 42 (41.6%) scored ≥ 24 on the K-10 scale (95% CI: 32.0% - 51.2%) indicating moderate to severe psychological distress and 32 (31.7%) scored ≥ 50 on the PCL-C checklist suggesting severe PTSD (95% CI: 24.5% - 42.9%). High scores on the K-10 were found more among men than women (17 [37.8%] vs. 4 [7.1%]; p ≤ 0.001). Post-traumatic stress disorder was more in the younger age group (p ≤ 0.03), in those reporting anxiety (p = 0.005) and those with more co-morbidities (p ≤ 0.001)., Conclusion:  This study revealed the grave psychological impact of the COVID-19 pandemic on frontline clinical health workers in Lesotho.Contribution: These data will assist health leaders and policymakers to implement mental health support interventions for health workers in future.

Introduction: Young women from the low-middle-income country of Lesotho in southern Africa frequently report limited knowledge regarding sexual and reproductive health issues and engage in risky sexual behaviors. The purpose of this study is to describe the adaptation of an evidence-based conversational agent system for implementation in Lesotho and provide qualitative data pertaining to the success of the said adaptation., Methods: An embodied conversational agent system used to provide preconception health advice in the United States was clinically and culturally adapted for use in the rural country of Lesotho in southern Africa. Inputs from potential end users, health leaders, and district nurses guided the adaptations. Focus group discussions with young women aged 18-28 years who had used the newly adapted system renamed "Nthabi" for 3-4 weeks and key informant interviews with Ministry of Health leadership were conducted to explore their views of the acceptability of the said adaptation. Data were analyzed using NVivo software, and a thematic content analysis approach was employed in the study., Results: A total of 33 women aged 18-28 years used Nthabi for 3-4 weeks; eight (24.2%) of them were able to download and use the app on their mobile phones and 25 (75.8%) of them used the app on a tablet provided to them. Focus group participants ( n  = 33) reported that adaptations were culturally appropriate and provided relevant clinical information. The participants emphasized that the physical characteristics, personal and non-verbal behaviors, utilization of Sesotho words and idioms, and sensitively delivered clinical content were culturally appropriate for Lesotho. The key informants from the Ministry leadership ( n  = 10) agreed that the adaptation was successful, and that the system holds great potential to improve the delivery of health education in Lesotho. Both groups suggested modifications, such as using the local language and adapting Nthabi for use by boys and young men., Conclusions: Clinically tailored, culturally sensitive, and trustworthy content provided by Nthabi has the potential to improve accessibility of sexual and reproductive health information to young women in the low-middle-income country of Lesotho., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Nkabane-Nkholongo, Mokgatle, Bickmore, Julce and Jack.)

Background: Housing security is a key social determinant of behavior related to health outcomes., Objective: The purpose of this study was to develop a new patient-reported outcome measure that evaluates aspects of housing security for use in the Re-Engineered Discharge for Diabetes-Computer Adaptive Test (REDD-CAT) measurement system., Design: Qualitative data, literature reviews, and cross-sectional survey study., Participants: A total of 225 people with T2DM provided responses to the items in this item pool., Main Measures: A new item pool that evaluates important aspects of housing security was developed using stakeholder data from focus groups of persons with T2DM., Key Results: For the Housing Affordability scale, factor analysis (both exploratory and confirmatory) supported the retention of six items. Of these items, none exhibited sparse cells or problems with monotonicity; no items were deleted due to low item-adjusted total score correlations. For the six affordability items, a constrained graded response model indicated no items exhibited misfit; thus, all were retained. No items indicated differential item functioning (examined for age, sex, education, race, and socioeconomic status). Thus, the final Affordability item bank comprised six items. A Housing Safety index (three items) and a Home Features index (eight items) were also developed. Reliability (i.e., internal consistency and test-retest reliability) and validity (i.e., convergent, discriminant, and known-groups) of the new measures were also supported., Conclusions: The REDD-CAT Housing Security Measure provides a reliable and valid assessment of housing affordability, safety, and home features in people with type 2 diabetes mellitus. Future work is needed to establish the clinical utility of this measure in other clinical populations., (© 2023. The Author(s), under exclusive licence to Society of General Internal Medicine.)

Purpose: To develop a new computer adaptive test that evaluates important aspects of medication adherence for persons with type 2 diabetes mellitus., Methods: Two hundred and twenty-five people with type 2 diabetes mellitus completed 41 items related to medication adherence., Results: Exploratory analysis supported the essential unidimensionality of the initial item pool. Five items were deleted due to low item-adjusted total score correlations (resulting in 36 items). Confirmatory factor analysis supported the retention of 27 items. A graded response model identified no items for exclusion, based on misfit. No items were flagged for meaningful differential item functioning (DIF). The final item bank is comprised of 27 items; an associated 6-item short form was constructed that balanced both psychometric factors (e.g., item information values) and clinical input. Initial analysis of the simulated CAT and static short form supported both the reliability (i.e., internal consistency and test-retest reliability) and validity (i.e., convergent, discriminant, and known groups) of both administration formats., Conclusions: The new medication adherence item bank provides a reliable and valid assessment of the ability to take medications accurately among people with T2DM; it will be available in early 2023 through healthmeasures.net., (© 2022. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Purpose: The purpose of this study was to develop a new measure to evaluate the ability to receive medical services when needed among persons with type 2 diabetes mellitus., Methods: The Healthcare Access measure was developed using data from 225 persons with type 2 diabetes mellitus who completed an item pool comprised of 54 questions pertaining to their experience accessing healthcare services., Results: Exploratory and confirmatory factor analyses supported the retention of 45 items. In addition, a constrained graded response model (GRM), as well as analyses that examined item misfit and differential item functioning (investigated for age, sex, education, race, and socioeconomic status), supported the retention of 44 items in the final item bank. Expert review and GRM item calibration products were used to inform the selection of a 6-item static short form and to program the Healthcare Access computer adaptive test (CAT). Preliminary data supported the reliability (i.e., internal consistency and test-retest reliability) and validity (i.e., convergent, discriminant, and known-groups) of the new measure., Conclusions: The new Healthcare Access item bank can be used to examine the experiences that persons with type 2 diabetes mellitus have with healthcare access, to better target treatment improvements and mitigate disparities; it will be available as a part of the Neuro-Qol measurement system through healthmeasures.net and the PROMIS Application Programmable Interface (API) in early 2023., (© 2022. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Purpose: The purpose of this study was to develop a new measure, the Re-Engineered Discharge for Diabetes Computer Adaptive Test (REDD-CAT) Illness Burden item bank, to evaluate the impact that a chronic condition has on independent living, the ability to work (including working at home), social activities, and relationships., Methods: Semi-structured interviews were used to inform the development of an item pool (47 items) that captured patients' beliefs about how a diagnosis of type 2 diabetes interferes with different aspects of their lives. The Illness Burden item bank was developed and tested in 225 people with type 2 diabetes mellitus., Results: No items had sparse response option cells or problems with monotonicity; two items were deleted due to low item-rest correlations. Factor analyses supported the retention of 29 items. With those 29 remaining items, a constrained (common slope) graded response model fit assessment indicated that two items had misfit; they were excluded. No items displayed differential item functioning by age, sex, education, or socio-economic status. The final item bank is comprised of 27 items. Preliminary data supported the reliability (internal consistency and test-retest reliability) and validity (convergent, discriminant, and known-groups) of the new bank., Conclusion: The Illness Burden item bank can be administered as a computer adaptive test or a 6-item short form. This new measure captures patients' perceptions of the impact that having type 2 diabetes has on their daily lives; it can be used in conjunction with the REDD-CAT measurement system to evaluate important social determinants of health in persons with type 2 diabetes mellitus., (© 2022. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Objective: To explore opportunities to change increasing weight gain trajectories for women during their reproductive lives, focusing on optimising health before pregnancy. Type of program: Identifying optimal policies, health promotion and health services to support preconception health for women (with a focus on achieving a healthy weight)., Methods: Narrative description of changing policies and approaches for improving preconception health., Results: Preconception preventive health priorities have been clearly determined globally and nationally. However, further rigorous research for effective interventions to facilitate healthy weight and other aspects of preconception health, alongside effective policies and strategies for implementing these interventions, remains potentially important. Barriers for women, their partners, families, communities and health professionals must be overcome and enablers fostered. The inclusion of preconception lifestyle health to tackle maternal and childhood obesity as a key priority of the World Health Organization as well as in the Australian National obesity strategy 2022-2032 are steps in the right direction., Lessons Learnt: Improving health across the life course requires a whole of system, integrated and equitable approach to health promotion, healthcare and policy. This includes integrating education, work, community environments, and health professionals to engage girls and young women well before pregnancy, to optimise their health. National coordination to determine core indicators and systems to evaluate and monitor change has been shown to help internationally and can be applied in Australia., Competing Interests: None declared.

Public-private partnerships (PPP) may increase healthcare quality but lack longitudinal evidence for success. The Queen 'Mamohato Memorial Hospital (QMMH) in Lesotho is one of Africa's first healthcare PPPs. We compare data from 2012 and 2018 on capacity, utilization, quality, and outcomes to understand if early documented successes have been sustained using the same measures over time. In this observational study using administrative and clinical data, we assessed beds, admissions, average length of stay (ALOS), outpatient visits, and patient outcomes. We measured triage time and crash cart stock through direct observation in 2013 and 2020. Operational hospital beds increased from 390 to 410. Admissions decreased (-5.3%) while outpatient visits increased (3.8%). ALOS increased from 5.1 to 6.5 days. Occupancy increased from 82% to 99%; half of the wards had occupancy rates ≥90%, and Neonatal ward occupancy was 209%. The proportion of crash cart stock present (82.9% to 73.8%) and timely triage (84.0% to 27.6%) decreased. While overall mortality decreased (8.0% to 6.5%) and neonatal mortality overall decreased (18.0% to 16.3%), mortality among very low birth weight neonates increased (30.2% to 36.8%). Declines in overall hospital mortality are promising. Yet, continued high occupancy could compromise infection control and impede response to infections, such as COVID-19. High occupancy in the Neonatal ward suggests that the population need for neonatal care outpaces QMMH capacity; improvements should be addressed at the hospital and systemic levels. The increase in ALOS is acceptable for a hospital meant to take the most critical cases. The decline in crash cart stock completeness and timely triage may affect access to emergency treatment. While the partnership itself ended earlier than anticipated, our evaluation suggests that generally the hospital under the PPP was operational, providing high-level, critically needed services, and continued to improve patient outcomes. Quality at QMMH remained substantially higher than at the former Queen Elizabeth II hospital., Competing Interests: The authors have declared that no competing interests exist.

Background: Responding to the shift toward value-based care, hospitals engaged in widespread experimentation of implementing transitional care (TC) strategies to improve patient experience and reduce unnecessary readmissions. However, which groups of these strategies are most strongly associated with better outcomes remains unknown., Methods: Using a retrospective longitudinal design, we collected hospitals' TC strategy implementation data for 370 U S. hospitals and obtained claims data for 2.4 million Medicare fee-for-service beneficiaries hospitalized at them from 2009 to 2014. We applied estimated mixed-effects regression models controlling for patient, hospital, and community covariates to assess relationships between TC strategy groups and trends in hospitals' 30-day hospital readmissions, with observation stay and mortality rates as secondary outcomes., Results: Hospitals' adoption of TC groups was associated with higher readmission rates at baseline and larger readmission rate reductions compared to not adopting any of 5 TC groups. The TC group including timely information exchange across care settings, engaging patients and caregivers in education, and/or identifying and addressing patients' transition needs was associated with the largest reductions. Hospitals not implementing any of the 5 TC groups had higher mortality rates and lower observation stay rates throughout the study period., Conclusions: Our findings suggest that timely information sharing among providers across the care continuum and engaging patients in discharge planning and education may correspond with reduced readmissions., Implications: Our research suggests that hospitals responded to shifts in policy by implementing a diversity of TC strategy combinations; it also provides guidance regarding which combinations of TC strategies corresponded with larger readmission reductions., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Purpose: To determine if hospitalized patients with depressive symptoms will benefit from post-discharge depression treatment with care transition support., Methods: This is a randomized controlled trial of hospitalized patients with patient health questionnaire-9 score of 10 or more. We delivered the Re-Engineered Discharge (RED) and randomized participants to groups receiving RED-only or RED for Depression (RED-D), a 12-week post-discharge telehealth intervention including cognitive behavioral therapy, self-management support, and patient navigation. Primary outcomes were hospital readmission and reutilization rates at 30 and 90 days post discharge., Results: We randomized 709 participants (353 RED-D, 356 RED-only). At 90 days, 265 (75%) intervention participants had received at least 1 RED-D session (median 4). At 30 days, the intention-to-treat analysis showed no differences between RED-D vs RED-only in hospital readmission (9% vs 10%, incidence rate ratio [IRR] 0.92 [95% CI, 0.56-1.52]) or reutilization (27% vs 24%, IRR 1.14 [95% CI, 0.85-1.54]). The intention-to-treat analysis also showed no differences at 90 days in readmission (28% vs 21%, IRR 1.30 [95% CI, 0.95-1.78]) or reutilization (70% vs 57%, IRR 1.22 [95% CI, 1.01-1.49]). In the as-treated analysis, each additional RED-D session was associated with a decrease in 30- and 90-day readmissions. At 30 days, among 104 participants receiving 3 or more sessions, there were fewer readmissions (3% vs 10%, IRR 0.30 [95% CI, 0.07-0.84]) compared with the control group. At 90 days, among 109 participants receiving 6 or more sessions, there were fewer readmissions (11% vs 21%, IRR 0.52 [95% CI, 0.27-0.92]). Intention-to-treat analysis showed no differences between study groups on secondary outcomes., Conclusions: Care transition support and post-discharge depression treatment can reduce unplanned hospital use with sufficient uptake of the RED-D intervention., (© 2022 Annals of Family Medicine, Inc.)

Black men have the highest age-adjusted death rate of any major race-gender group in America. Understanding their perceived barriers to accessing health care may benefit future interventions working to increase Black men's health care engagement. Data collected from focus groups of Black men( N = 67), key informant interviews( N = 12), and interviews( N = 5) with participants who pilot tested an online health education system (called "Gabe") were analyzed to explore their health care experiences and how computer-based health programs might better assist Black men. Concerns pertaining to health care systems' failure to recognize the diversity among Black men, and physicians' lack of sociocultural awareness about the challenges they regularly face, were most salient. Building trust with providers was cited as being central to engagement, with Gabe users perceiving the system to be both trustworthy and accessible. Participants reported an openness to technology assisting with health management and provided suggestions of how online systems can meet the needs of Black men.

Background: To improve the delivery and reach of primary health care, a robust scientific foundation driven by research is needed. However, few family physicians conduct research, especially in sub-Saharan Africa. Early-career and trainee family physicians are a key part of the primary care research pipeline and have an expressed need for research training and mentorship., Objective: AfriWon Research Collaborative (ARC) was an online research training and mentorship pilot program whose objective was to increase research activity among participants from AfriWon Renaissance, the family physician young doctors' movement of sub-Saharan Africa., Methods: ARC utilized a 10-module online curriculum, supported by peer and faculty e-mentorship, to guide participants through writing a research protocol. The feasibility, acceptability, and scalability of this program was evaluated via a mixed-methods RE-AIM-guided process evaluation using descriptive statistics and inductive/deductive thematic analysis., Findings: The pilot reached participants from Botswana, Democratic Republic of the Congo, Ghana, Nigeria and Sierra Leone and was adopted by mentors from 11 countries across three continents. Four of the 10 pilot participants completed a full research protocol by the end of the six-month core program. Seven out of the 10 participants, and nine out of the 15 mentors, planned to continue their mentorship relationships beyond the core program. The program helped instill a positive research culture in active participants. Some participants' and mentors' engagement with the ARC program was limited by confusion over mentorship structure and role, poor network connectivity, and personal life challenges., Conclusions: Online research training and mentorship for trainee and early-career family physicians in sub-Saharan Africa is feasible and acceptable to participants and mentors. Similar programs must pay careful attention to mentorship training and provide a flexible yet clearly organized structure for mentee-mentor engagement. Additional work is needed to determine optimal implementation strategies and ability to scale., Competing Interests: The authors: Bolatito B. Fatusin, MBBS, FMCFM; Hithaishini Kodicherla, MPH; Kenneth Yakubu, MPhil, FWACP (Fam Med); Pius Ameh, FWACP (Fam Med); Ethan Rhoad, MPH; and Nancy A. Scott, DrPH, have no conflicting or competing interests to declare. Authors Chelsea M. McGuire, MD, MS and Brian W. Jack, MD are co-principal investigators on a Consortium of University for Global Health (CUGH) Tom Hall Global Health Education grant that supported this project, but did not directly fund either person. Alexandra van Waes was supported by a grant by Boston University Undergraduate Research Opportunities Program., (Copyright: © 2021 The Author(s).)

Importance: Healthy nutrition and appropriate supplementation during preconception have important implications for the health of the mother and newborn. The best way to deliver preconception care to address health risks related to nutrition is unknown., Methods: We conducted a secondary analysis of data from a randomized controlled trial designed to study the impact of conversational agent technology in 13 domains of preconception care among 528 non-pregnant African American and Black women. This analysis is restricted to those 480 women who reported at least one of the ten risks related to nutrition and dietary supplement use., Interventions: An online conversational agent, called "Gabby", assesses health risks and delivers 12 months of tailored dialogue for over 100 preconception health risks, including ten nutrition and supplement risks, using behavioral change techniques like shared decision making and motivational interviewing. The control group received a letter listing their preconception risks and encouraging them to talk to a health care provider., Results: After 6 months, women using Gabby (a) reported progressing forward on the stage of change scale for, on average, 52.9% (SD, 35.1%) of nutrition and supplement risks compared to 42.9% (SD, 35.4) in the control group (IRR 1.22, 95% CI 1.03-1.45, P = 0.019); and (b) reported achieving the action and maintenance stage of change for, on average, 52.8% (SD 37.1) of the nutrition and supplement risks compared to 42.8% (SD, 37.9) in the control group (IRR 1.26, 96% CI 1.08-1.48, P = 0.004). For subjects beginning the study at the contemplation stage of change, intervention subjects reported progressing forward on the stage of change scale for 75.0% (SD, 36.3%) of their health risks compared to 52.1% (SD, 47.1%) in the control group (P = 0.006)., Conclusion: The scalability of Gabby has the potential to improve women's nutritional health as an adjunct to clinical care or at the population health level. Further studies are needed to determine if improving nutrition and supplement risks can impact clinical outcomes including optimization of weight., Clinical Trial Registration: ClinicalTrials.gov, identifier NCT01827215., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Gardiner, Bickmore, Yinusa-Nyahkoon, Reichert, Julce, Sidduri, Martin-Howard, Woodhams, Aryan, Zhang, Fernandez, Loafman, Srinivasan, Cabral and Jack.)

Background: Improving the health of women before pregnancy and throughout a woman's lifespan could mitigate disparities and improve the health and wellbeing of women, infants and children. The preconception period is important for reducing health risks associated with poor maternal, perinatal and neonatal outcomes, and eliminating racial and ethnic disparities in maternal and child health. Low cost health information technology interventions provided in community-based settings have the potential to reach and reduce disparities in health outcomes for socially disadvantaged, underserved and health disparity populations. These interventions are particularly important for Black and African American women who have a disproportionate burden of pregnancy-related complications and infant mortality rates compared to any other racial and ethnic group in the U.S., Methods: This is a hybrid type II implementation-effectiveness cohort study aimed at evaluating appropriateness, acceptability and feasibility implementation outcomes, while also systematically examining the clinical effectiveness of a preconception care (PCC) intervention, the Gabby System, for Black and African American women receiving health services in community-based sites. The intervention will be implemented in six Community Health Centers and six Healthy Start programs across the U.S. Each study site will recruit and enroll 25-50 young Black and African American women who will participate in the intervention for a 6-month period. Appropriateness, acceptability and feasibility of implementing the PCC intervention will be assessed using: 1) Qualitative data derived from individual interviews with Gabby System end-users (clients and patients) and site staff; and, 2) Quantitative data from staff surveys, Gabby System usage and uptake. Aggregate health risk and utilization measures collected directly from the Gabby server will be used to examine the effectiveness of the Gabby System on self-reported behavior change., Discussion: This study will examine implementation outcomes and clinical effectiveness of an evidence-based PCC intervention for Black and African American women receiving services in Healthy Start programs and Community Health Centers. Contextual factors that influence uptake and appropriate implementation strategies will be identified to inform future scalability of the intervention., Trial Registration: ClinicalTrials.gov NCT04514224 . Date of registration: August 14, 2020. Retrospectively Registered.

Background: Preconception care focuses on improving women's health before pregnancy as a means to improve their health and future pregnancy outcomes. How to effectively deliver such care is unknown. The aim of this research was to assess the impact of an embodied conversational agent system on preconception risks among African American and Black women., Methods: We did an open-label, randomised controlled trial of women aged 18-34 years, self-identified as African American or Black, or both, and not pregnant, recruited from 35 states in the USA. Sealed allocation envelopes (in permuted blocks of six and eight, prepared using a random number generator) were opened after enrolment. Intervention participants received an online conversational agent called Gabby that assessed 102 preconception risks and delivered 12 months of tailored dialogue using synthesised speech, non-verbal behaviour, visual aids, and health behaviour change techniques such as motivational interviewing. The control group received a letter listing their preconception risks and encouraging them to talk with a clinician. The primary outcome was the proportion of identified risks at the action or maintenance stage of change at months 6 and 12. The study is registered with ClinicalTrials.gov, NCT01827215., Findings: From March 11, 2014, through July 8, 2018, 528 women recruited from 35 states and 242 cities across the USA received the Gabby intervention (n=262) or were assigned to the control group (n=266). Participants identified a mean of 21 preconception risks per woman (SD 9·9). In the intention-to-treat analysis, at 6 months, intervention women reported reaching the action or maintenance stage of change for 50·0% (SD 28·9) of those preconception risks identified compared with 42·7% (28·3) in the control group (incidence rate ratio 1·16, 95% CI 1·07-1·26; p=0·0004). This result persisted at 12 months., Interpretation: The Gabby system has the potential to improve women's preconception health. Further research is needed to determine if improving preconception risks impacts outcomes such as preterm delivery., Funding: National Institute for Minority Health and Health Disparities., (Copyright © 2020 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Competing Interests: Conflict of interest: none declared.

Purpose: Despite concerted actions to streamline care transitions, the journey from hospital to home remains hazardous for patients and caregivers. Remarkably little is known about the patient and caregiver experience during care transitions, the services they need, or the outcomes they value. The aims of this study were to (1) describe patient and caregiver experiences during care transitions and (2) characterize patient and caregiver desired outcomes of care transitions and the health services associated with them., Methods: We interviewed 138 patients and 110 family caregivers recruited from 6 health networks across the United States. We conducted 34 homogenous focus groups (103 patients, 65 caregivers) and 80 key informant interviews (35 patients, 45 caregivers). Audio recordings were transcribed and analyzed using principles of grounded theory to identify themes and the relationship between them., Results: Patients and caregivers identified 3 desired outcomes of care transition services: (1) to feel cared for and cared about by medical providers, (2) to have unambiguous accountability from the health care system, and (3) to feel prepared and capable of implementing care plans. Five care transition services or provider behaviors were linked to achieving these outcomes: (1) using empathic language and gestures, (2) anticipating the patient's needs to support self-care at home, (3) collaborative discharge planning, (4) providing actionable information, and (5) providing uninterrupted care with minimal handoffs., Conclusions: Clear accountability, care continuity, and caring attitudes across the care continuum are important outcomes for patients and caregivers. When these outcomes are achieved, care is perceived as excellent and trustworthy. Otherwise, the care transition is experienced as transactional and unsafe, and leaves patients and caregivers feeling abandoned by the health care system., Competing Interests: Conflicts of interest: S.E.M. is a non-product speaker for Merck & Co. M.V.W. has received grant and contract funding from the Patient-Centered Outcomes Research Institute, AHRQ, BlueCross BlueShield of Illinois, and has received royalty payments from Elsevier for the reference text book Comprehensive Hospital Medicine. To the best of our knowledge, no other conflicts of interest, financial or other, exist for any of the authors., (© 2018 Annals of Family Medicine, Inc.)

Background: Hospitalized patients are frequently unprepared to care for themselves after discharge often leading to unplanned hospital readmission. One strategy to reduce readmission rates is improving the quality of patient education and preparation before hospital discharge. The ReEngineered Discharge (RED) is a standardized hospital-based program designed to provide patients and caregivers the information they need to continue care at home., Objectives: We sought to study the impact of the RED intervention on posthospitalization adult patient experience scores in an urban academic safety-net hospital., Methods: We conducted a descriptive study of a pilot program that compared posthospitalization survey responses to the Press Ganey survey item "Instructions were given about how to care for yourself at home." We compared the survey results for 3 groups of adult patients: those receiving the RED program, those receiving a standard discharge on the same hospital unit, and those receiving a standard discharge on other hospital units., Results: A greater percentage of adult patients who received the RED discharge program rated the quality of their discharge as "very good" as compared to those receiving a standard discharge on the same hospital unit and those receiving a standard discharge on other hospital units (61%, 35%, and 41%, respectively, P = .0001)., Conclusion: Delivery of a standardized hospital discharge program resulted in a larger proportion of top-box "very good" responses on a Press Ganey posthospitalization survey. Future research should examine whether hospital-based transition programs can sustain improvement in patient experience measures and whether these improvements can be observed in other patient populations., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: This randomized controlled trial evaluates the feasibility of using an Embodied Conversational Agent (ECA) to teach lifestyle modifications to urban women., Methods: Women were randomized to either 1) an ECA (content included: mindfulness, stress management, physical activity, and healthy eating) or 2) patient education sheets mirroring same content plus a meditation CD/MP3 once a day for one month. General outcome measures included: number of stress management techniques used, physical activity levels, and eating patterns., Results: Sixty-one women ages 18 to 50 were enrolled. On average, 51% identified as white, 26% as black, 23% as other races; and 20% as Hispanic. The major stress management techniques reported at baseline were: exercise (69%), listening to music (70%), and social support (66%). After one month, women randomized to the ECA significantly decreased alcohol consumption to reduce stress (p=0.03) and increased daily fruit consumption by an average of 2 servings compared to the control (p=0.04)., Conclusion: It is feasible to use an ECA to promote health behaviors on stress management and healthy eating among diverse urban women., Practice Implications: Compared to patient information sheets, ECAs provide promise as a way to teach healthy lifestyle behaviors to diverse urban women., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Background: In 2011, fee-for-service patients with both Medicare and Medicaid (dual eligible) sustained $319.5 billion in health care costs., Objective: To describe the emergency department (ED) use and hospital admissions of adult dual eligible patients aged under 65 years who used an urban safety net hospital., Methods: This was a retrospective database analysis of patients aged between 18 and 65 years with Medicare and Medicaid, who used an urban safety net academic health center between January 1, 2011, and December 31, 2011. We compared patients with and without behavioral health illness. The main outcome measures were hospital admission and ED use. Chi-square and Wilcoxon rank-sum tests were used for descriptive statistics on categorical and continuous variables, respectively. Greedy propensity score matching was used to control for confounding factors. Rate ratios (RR) and 95% confidence intervals (CI) were determined after matching and after adjusting for those variables that remained significantly different after matching., Results: In 2011, 10% of all fee-for-service dual eligible patients aged less than 65 years in Massachusetts were seen at Boston Medical Center. Data before propensity score matching showed significant differences in age, sex, race/ethnicity, marital status, education, employment, physical comorbidities, and Charlson Comorbidity Index score between patients with and without behavioral health illness. Analysis after propensity score matching found significant differences in sex, Hispanic race, and other education and employment status. Compared with patients without behavioral health illness, patients with behavioral health illness had a higher RR for hospital admissions (RR = 2.07; 95% CI = 1.81-2.38; P < 0.001) and ED use (RR = 1.61; 95% CI = 1.46-1.77; P < 0.001). Results were robust after adjusting for characteristics that remained statistically significantly different after propensity score matching., Conclusions: Adult dual eligible patients aged less than 65 years with behavioral health illness in the Medicaid fee-for-service plan had significantly higher rates of hospital admission and ED use compared with dual eligible patients without behavioral health illness at the largest urban safety net medical center in New England. Safety net hospitals care for a large proportion of dual eligible patients with behavioral health illness. Further research is needed to elucidate the systems-related and patient-centered factors contributing to the utilization behaviors of this patient population., Disclosures: This research was funded in part by a National Research Service Award (T3HP10028-14-01). The authors have no conflicts of interests to disclose. Cancino had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design were contributed by Cancino, Jack, and Burgess, with assistance from Cremieux. Cancino and Cremieux took the lead in data collection, along with Jack and Burgess, and data interpretation was performed by Jarvis, Cummings, and Cooper, along with the other authors. The manuscript was written primarily by Cancino, along with Jack and Burgess, and revised primarily by Cancino, along with the other authors.

Background: Project Re-Engineered Discharge (RED) is an evidence-based strategy to reduce readmissions disseminated and adapted by various health systems across the country. To date, little is known about how adapting Project RED from its original protocol impacts RED implementation and/or sustainability. The goal of this study was to identify and characterize contextual factors influencing how five California hospitals adapted and implemented RED and the subsequent impact on RED program sustainability., Methods: Participant observation and key informant and focus group interviews with 64 individuals at five California hospitals implementing RED in 2012 and 2013 were conducted. These involved hospital leadership, personnel responsible for Project RED implementation, hospital staff, and clinicians. Interview transcripts were coded and analyzed using a modified grounded theory approach and constant comparative analysis., Results: Both internal and external contextual factors were identified that influenced hospitals' decisions on RED adaptation and implementation. These also impacted RED sustainability. External factors included: impending federal penalties for hospitals with high readmission rates targeting specific diagnoses, and access to external funding and technical support to help hospitals implement RED. Internal or organizational level contextual factors included: committed leadership prioritizing Project RED; RED adaptations; depth, accountability and influence of the implementation team; sustainability planning; and hospital culture. Only three of the five hospitals continued Project RED beyond the implementation period., Conclusions: The sustainability of RED in participating hospitals was only possible when hospitals approached RED implementation as a transformational process rather than a patient safety project, maintained a high level of fidelity to the RED protocol, and had leadership and an implementation team who embraced change and failure in the pursuit of better patient care and outcomes. Hospitals who were unsuccessful in implementing a sustainable RED process lacked all or most of these components in their approach.

Background: The Re-Engineered Discharge (Project RED) reduces 30-day readmission rates by 30%. However, our data indicates that for patients displaying depressive symptoms during hospitalization, Project RED is less effective in preventing unplanned readmission. We aim to examine the effectiveness of RED-D, a modified brief Cognitive behavioral therapy (CBT) protocol delivered as a post-discharge extension of the Re-Engineered Discharge, in reducing 30-day readmissions rates and emergency department (ED) use as well as depressive symptoms for medical patients with comorbid depressive symptoms., Methods: This paper details the study design and implementation of an ongoing, federally funded randomized controlled trial of our post-discharge mental health intervention, RED-D, compared to the RED plus usual care. This research has two primary objectives: (1) to determine whether RED-D delivered telephonically by a mental health professional immediately following discharge is effective in reducing hospital readmission and emergency department use for patients displaying depressive symptoms during their inpatient stay, and (2) to examine whether this approach yields a clinically significant reduction in depressive symptoms. We intend to recruit 1200 participants randomized to our intervention, RED-D (n=600), and to RED plus usual care (n=600)., Conclusions: Hospitalized patients with depressive symptoms are at increased risk for 30-day readmission. We aim to conduct a randomized clinical trial to evaluate the comparative effectiveness of RED-D, our post-discharge modified brief CBT intervention compared to RED alone in reducing readmissions and depressive symptoms for this at-risk population., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: Little is known about the use of Stress Management and Relaxation Techniques (SMART) in racially diverse inpatients. We hope to identify socioeconomic status (SES) factors, health behavior factors, and clinical factors associated with the use of SMART., Design and Main Outcome Measures: We conducted a secondary analysis of baseline data from 623 hospitalized patients enrolled in the Re-Engineered Discharge (RED) clinical trial. We assessed socio-demographic characteristics and use of SMART. We used bivariate and multivariate logistic regression to test the association of SMART with socio-demographic characteristics, health behaviors, and clinical factors., Results: A total of 26.6% of participants reported using SMART and 23.6% used mind body techniques. Thirty six percent of work disabled patients, 39% of illicit drug users, and 38% of participants with depressive symptoms used SMART. Patients who both reported illicit drug use and screened positive for depression had significantly increased odds of using SMART [OR=4.94, 95% CI (1.59, 15.13)]. Compared to non-Hispanic whites, non-Hispanic blacks [0.55 (0.34-0.87)] and Hispanic/other race individuals [0.40 (0.20-0.76)] were less likely to use SMART., Conclusions: We found greater utilization of SMART among all racial groups compared to previous national studies. In the inner city inpatient setting, patients with depression, illicit drug use, and work disability reported higher rates of using SMART., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Objective: To explore inpatient reconciliation of dietary supplement (DS) use and determine characteristics associated with DS documentation., Methods: We analyzed DS use among 558 inpatients recruited from the Re-Engineered Discharge clinical trial to identify: (1) if patients self-reported DS and (2) if DS use was documented at admission. We examined socio-demographics for association with documentation using chi squares and t-tests. Logistic regression was performed to assess adjusted associations with DS documentation., Results: Sixty percent reported DS use (n=333). Among users, 36% had admission DS documentation, 20% were asked about use at admission, 18% reported disclosing use to a provider, and 48% reported they would continue to use DS. Overall, 6% of participants were asked, disclosed, and had documentation of DS. Logistic regression revealed increased age associated with lower odds of DS documentation. Identifying as Hispanic or African American reduces DS documentation odds compared to those identifying as white., Conclusions: There is lack of consistent DS medical reconciliation in the inpatient setting. While more than half of patients used DS prior to hospitalization, most were not asked about use on admission., Practice Implications: This study adds to literature on medical reconciliation which requires that providers inquire and document patient DS use., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Abstract -Public-private partnerships (PPPs) seek to expand access to quality health services in ways that best leverage the capacities and resources of both sectors. There are few examples of PPPs in the hospital sector in developing countries, and little is known about how the involvement of the private sector transforms the delivery of health services in this context. In 2006, the government of Lesotho adopted a PPP approach for the health sector, contracting out to design, build, and operate a hospital network in its capital district. This case study examines differences between a government-run hospital and the PPP-run hospital that replaced it, using in-depth interviews with key informants, observation of management systems, and document review. Key informants emphasized changes in infrastructure, communication, human resource management, and organizational culture that improved quality and demand for services. Important drivers of improved performance included better defined policies and procedures, empowerment and training of managers and staff, and increased accountability. Well-functioning support systems kept the hospital clean and equipment functioning, reduced stock-outs, and allowed staff to do the jobs they were trained to do. The Lesotho PPP model provides insight into the mechanisms by which public-private partnerships may increase access and quality of care.

Purpose. To identify characteristics associated with the use of potentially harmful combinations of dietary supplements (DS) and cardiac prescription medications in an urban, underserved, inpatient population. Methods. Cardiac prescription medication users were identified to assess the prevalence and risk factors of potentially harmful dietary supplement-prescription medication interactions (PHDS-PMI). We examined sociodemographic and clinical characteristics for crude (χ (2) or t-tests) and adjusted multivariable logistic regression associations with the outcome. Results. Among 558 patients, there were 121 who also used a DS. Of the 110 participants having a PHDS-PMI, 25% were asked about their DS use at admission, 75% had documentation of DS in their chart, and 21% reported the intention to continue DS use after discharge. A multivariable logistic regression model noted that for every additional medication or DS taken the odds of having a PHDS-PMI increase and that those with a high school education are significantly less likely to have a PHDS-PMI than those with a college education. Conclusion. Inpatients at an urban safety net hospital taking a combination of cardiac prescription medications and DS are at a high risk of harmful supplement-drug interactions. Providers must ask about DS use and should consider the potential for interactions when having patient discussions about cardiac medications and DS.

Background: Evidence suggests depression increases hospital readmission risk., Objective: Determine whether depressive symptoms are associated with unplanned readmission within 30 days of discharge of general medical patients., Design: Secondary analysis of the Project Re-Engineered Discharge (RED) randomized controlled trials., Setting: Urban academic safety-net hospital., Patients: A total of 1418 hospitalized adult English-speaking patients., Intervention: The 9-Item Patient Health Questionnaire (PHQ-9) was used to screen patients for depressive symptoms., Measurements: Hospital readmission within 30 days of discharge. Poisson regression was used to control for confounding variables., Results: There were 225 (16%) patients who screened positive for mild depressive symptoms (5 ≤PHQ-9 ≤ 9) and 336 (24%) for moderate or severe depressive symptoms (PHQ-9 ≥ 10). After controlling for confounders, a higher rate of readmission was observed in subjects with mild depressive symptoms compared to subjects with PHQ-9 <5, incidence rate ratio (IRR) 1.49 (95% confidence interval [CI]: 1.11-2.00). The adjusted IRR of readmission for those with moderate-to-severe symptoms was 1.96 (95% CI: 1.51-2.49) compared to those with no depression., Conclusions: Screening positive for mild and moderate-to-severe depressive symptoms during a hospitalization on a general medical service is associated with an increased dose-dependent readmission rate within 30 days of discharge in an urban, academic, safety-net hospital. Further research is needed to determine whether treatments targeting the reduction of depressive symptoms reduce the risk of readmission., (© 2014 Society of Hospital Medicine.)

While kidney transplantation offers several advantages in terms of improved clinical outcomes and quality of life compared to dialysis modalities, depressive symptoms are still present in approximately 25% of patients, rates comparable to that of the hemodialysis population. Correlates of depressive symptoms include marital status, income, kidney function, history of affective illness, malnutrition, and inflammation. Depressive symptoms are also associated with poor outcomes following kidney transplantation including nonadherence to immunosuppressant medication, graft failure, and all-cause mortality. Efforts to detect and treat depression should be a priority if one is to improve treatment adherence, quality of life, and outcomes in transplant recipients.

Background: Patient activation is linked to better health outcomes and lower rates of health service utilization. The role of patient activation in the rate of hospital readmission within 30 days of hospital discharge has not been examined., Methods: A secondary analysis using data from the Project RED-LIT randomized controlled trial conducted at an urban safety net hospital. Data from 695 English-speaking general medical inpatient subjects were analyzed. We used an adapted, eight-item version of the validated Patient Activation Measure (PAM). Total scores were categorized, according to standardized methods, as one of four PAM levels of activation: Level 1 (lowest activation) through Level 4 (highest activation). The primary outcome measure was total 30-day post-discharge hospital utilization, defined as total emergency department (ED) visits plus hospital readmissions including observation stays. Poisson regression was used to control for confounding., Results: Of the 695 subjects, 67 (9.6 %) were PAM Level 1, 123 (17.7 %) were Level 2, 193 (27.8 %) were Level 3, and 312 (44.9 %) were Level 4. Compared with highly activated patients (PAM Level 4), a higher rate of 30-day post-discharge hospital utilization was observed for patients at lower levels of activation (PAM Level 1, incident rate ratio [IRR] 1.75, 95 % CI,1.18 to 2.60) and (PAM Level 2, IRR 1.50, 95 % CI 1.06 to 2.13). The rate of returning to the hospital among patients at PAM Level 3 was not statistically different than patients with PAM Level 4 (IRR 1.30, 95 % CI, 0.94 to 1.80). The rate ratio for PAM Level 1 was also higher compared with Level 4 for ED use alone (1.68(1.07 to 2.63)) and for hospital readmissions alone (1.93 [1.22 to 3.06])., Conclusion: Hospitalized adult medical patients in an urban academic safety net hospital with lower levels of Patient Activation had a higher rate of post-discharge 30-day hospital utilization.

Although the evidence for the associations between preconceptional risk factors and adverse pregnancy outcomes is extensive, the effectiveness of preconceptional interventions to reduce risk factors and to improve pregnancy outcomes remains partly unclear. The objective of this review is to summarize the available effectiveness of lifestyle interventions prior to pregnancy for women in terms of behavior change and pregnancy outcome. A predefined search strategy was applied in electronic databases, and citation tracking was performed. Study selection was performed by 2 independent reviewers according to predefined criteria for eligibility: The intervention was performed preconceptionally on women regarding alcohol use, smoking, weight, diet/nutrition, physical activity, and folic acid status (fortification and supplementation) to achieve behavior change and/or improve pregnancy outcome. Quality and strength of evidence were assessed by 2 independent reviewers. A total of 4,604 potentially relevant records were identified, of which 44 records met the inclusion criteria. Overall, there is a relatively short list of core interventions for which there is substantial evidence of effectiveness when applied in the preconception period.

Little is known about the relationship between health literacy and complementary and alternative medicine (CAM) use in low-income racially diverse patients. The authors conducted a secondary analysis of baseline data from 581 participants enrolled in the Re-Engineered Discharge clinical trial. The authors assessed sociodemographic characteristics, CAM use, and health literacy. They used bivariate and multivariate logistic regression to test the association of health literacy with four patterns of CAM use. Of the 581 participants, 50% reported using any CAM, 28% used provider-delivered CAM therapies, 27% used relaxation techniques, and 21% used herbal medicine. Of those with higher health literacy, 55% used CAM. Although there was no association between health literacy and CAM use for non-Hispanic Black participants, non-Hispanic White (OR = 3.68, 95% CI [1.27, 9.99]) and Hispanic/other race (OR = 3.40, 95% CI [1.46, 7.91]) participants were significantly more likely to use CAM if they had higher health literacy. For each racial/ethnic group, there were higher odds of using relaxation techniques among those with higher health literacy. Underserved hospitalized patients use CAM. Regardless of race, patients with high health literacy make greater use of relaxation techniques.

Objective: Hospital discharge may be an opportunity to intervene among patients with substance use disorders to reduce subsequent hospital utilization. This study determined whether having a substance use disorder diagnosis was associated with subsequent acute care hospital utilization., Methods: We conducted an observational cohort study among 738 patients on a general medical service at an urban, academic, safety-net hospital. The main outcomes were rate and risk of acute care hospital utilization (emergency department visit or hospitalization) within 30 days of discharge. The main independent variable was presence of a substance use disorder primary or secondary discharge diagnosis code at the index hospitalization., Results: At discharge, 17% of subjects had a substance use disorder diagnosis. These patients had higher rates of recurrent acute care hospital utilization than patients without substance use disorder diagnoses (0.63 vs 0.32 events per subject at 30 days, P < 0.01) and increased risk of any recurrent acute care hospital utilization (33% vs 22% at 30 days, P < 0.05). In adjusted Poisson regression models, the incident rate ratio at 30 days was 1.49 (95% confidence interval, 1.12-1.98) for patients with substance use disorder diagnoses compared with those without. In subgroup analyses, higher utilization was attributable to those with drug diagnoses or a combination of drug and alcohol diagnoses, but not to those with exclusively alcohol diagnoses., Conclusions: Medical patients with substance use disorder diagnoses, specifically those with drug use-related diagnoses, have higher rates of recurrent acute care hospital utilization than those without substance use disorder diagnoses.