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Laily A, Duncan R, Gabhart KM, Nephew LD, Christy SM, Vadaparampil ST, Giuliano AR, Kasting ML. Differences in Provider Hepatitis C Virus Screening Recommendations by Patient Risk Status. Prev Med Rep 2024; 38:102602. [PMID: 38375175 PMCID: PMC10874862 DOI: 10.1016/j.pmedr.2024.102602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 01/05/2024] [Accepted: 01/06/2024] [Indexed: 02/21/2024] Open
Abstract
Providers' recommendation is among the strongest predictors to patients engaging in preventive care. Therefore, the aim of this study was to compare providers' Hepatitis C Virus (HCV) screening recommendation quality between high-risk and average-risk patients to determine if providers are universally recommending HCV screening, regardless of risk behaviors. This cross-sectional survey of 284 Indiana providers in 2020 assessed provider characteristics, HCV screening recommendation practices (strength, presentation, frequency, timeliness), self-efficacy, and barriers to recommending HCV screening. T-test and Chi-square compared recommendation practices for high-risk and average-risk patients. Prevalence ratios were calculated for variables associated with HCV recommendation strength comparing high-risk and average-risk patients. Logistic regression analyses examined factors associated with HCV recommendation strength for high- and average-risk patients, with odds ratios. Compared to average-risk patients, high-risk patients received higher proportion of HCV recommendations that were strong (70.4 % v. 42.4 %), routine (61.9 % v. 55.6 %), frequent (37.7 % v. 28 %), and timely (74.2 % v. 54.9 %) (P-values < 0.001). Compared to average-risk patients, providers with high-risk patients had a lower percentage of giving a strong recommendation if they were nurse practitioner (PR = 0.49). For high-risk patients, providers with higher self-efficacy (aOR = 2.16;95 %CI = 0.99-4.69) had higher odds, while those with higher perceived barriers (aOR = 0.19;95 %CI = 0.09-0.39) and those with an internal medicine specialty compared to family medicine (aOR = 0.22;95 %CI = 0.08-0.57) had lower odds of giving a strong recommendation. These data suggest providers are not universally recommending HCV screening for all adults regardless of reported risk. Future research should translate these findings into multilevel interventions to improve HCV screening recommendations regardless of patient risk status.
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Affiliation(s)
- Alfu Laily
- Department of Public Health, College of Health and Human Sciences, Purdue University, 820 Mitch Daniels Blvd, West Lafayette, IN 47907, USA
| | - Robert Duncan
- Department of Human Development and Family Studies, College of Health and Human Sciences, Purdue University, 1202 West State St., West Lafayette, IN 47907, USA
| | - Kaitlyn M. Gabhart
- Department of Psychology, Vanderbilt University, 230 Appleton Pl, Nashville, TN 37203, USA
| | - Lauren D. Nephew
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 340 W 10th St., Indianapolis, IN 46202, USA
| | - Shannon M. Christy
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, 12902 USF Magnolia Drive, Tampa, FL 33612, USA
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, 12902 USF Magnolia Drive, Tampa, FL 33612, USA
- Department of Oncological Sciences, University of South Florida, 12902 USF Magnolia Drive, Tampa, FL 33612, USA
- Center for Immunization and Infection Research in Cancer, Moffitt Cancer Center, 12902 USF Magnolia Drive, Tampa, FL 33612, USA
| | - Susan T. Vadaparampil
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, 12902 USF Magnolia Drive, Tampa, FL 33612, USA
- Department of Oncological Sciences, University of South Florida, 12902 USF Magnolia Drive, Tampa, FL 33612, USA
- Center for Immunization and Infection Research in Cancer, Moffitt Cancer Center, 12902 USF Magnolia Drive, Tampa, FL 33612, USA
| | - Anna R. Giuliano
- Center for Immunization and Infection Research in Cancer, Moffitt Cancer Center, 12902 USF Magnolia Drive, Tampa, FL 33612, USA
- Department of Cancer Epidemiology, Moffitt Cancer Center, 12902 USF Magnolia Drive, Tampa, FL 33612, USA
| | - Monica L. Kasting
- Department of Public Health, College of Health and Human Sciences, Purdue University, 820 Mitch Daniels Blvd, West Lafayette, IN 47907, USA
- Cancer Prevention and Control Program, Indiana University Simon Comprehensive Cancer Center, 535 Barnhill Dr., Indianapolis, IN 46202, USA
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Todahl J, Nekkanti A, Schnabler S. Universal Screening and Education: A Client-Centered Protocol for Normalizing Intimate Partner Violence Conversation in Clinical Practice. JOURNAL OF COUPLE & RELATIONSHIP THERAPY 2020. [DOI: 10.1080/15332691.2020.1835595] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Jeff Todahl
- Counseling Psychology and Human Services Department, University of Oregon, Eugene, Oregon, USA
| | - Akhila Nekkanti
- Counseling Psychology and Human Services Department, University of Oregon, Eugene, Oregon, USA
| | - Simone Schnabler
- Center for the Prevention of Abuse and Neglect, University of Oregon, Eugene, Oregon, USA
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Chang ET, Zulman DM, Nelson KM, Rosland AM, Ganz DA, Fihn SD, Piegari R, Rubenstein LV. Use of General Primary Care, Specialized Primary Care, and Other Veterans Affairs Services Among High-Risk Veterans. JAMA Netw Open 2020; 3:e208120. [PMID: 32597993 PMCID: PMC7324956 DOI: 10.1001/jamanetworkopen.2020.8120] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
IMPORTANCE Integrated health care systems increasingly focus on improving outcomes among patients at high risk for hospitalization. Examining patterns of where patients obtain care could give health care systems insight into how to develop approaches for high-risk patient care; however, such information is rarely described. OBJECTIVE To assess use of general and specialized primary care, medical specialty, and mental health services among patients at high risk of hospitalization in the Veterans Health Administration (VHA). DESIGN, SETTING, AND PARTICIPANTS This national, population-based, retrospective cross-sectional study included all veterans enrolled in any type of VHA primary care service as of September 30, 2015. Data analysis was performed from April 1, 2016, to January 1, 2019. EXPOSURES Risk of hospitalization and assignment to general vs specialized primary care. MAIN OUTCOME AND MEASURES High-risk veterans were defined as those who had the 5% highest risk of near-term hospitalization based on a validated risk prediction model; all others were considered low risk. Health care service use was measured by the number of encounters in general primary care, specialized primary care, medical specialty, mental health, emergency department, and add-on intensive management services (eg, telehealth and palliative care). RESULTS The study assessed 4 309 192 veterans (mean [SD] age, 62.6 [16.0] years; 93% male). Male veterans (93%; odds ratio [OR], 1.11; 95% CI, 1.10-1.13), unmarried veterans (63%; OR, 2.30; 95% CI, 2.32-2.35), those older than 45 years (94%; 45-65 years of age: OR, 3.49 [95% CI, 3.44-3.54]; 66-75 years of age: OR, 3.04 [95% CI, 3.00-3.09]; and >75 years of age: OR, 2.42 [95% CI, 2.38-2.46]), black veterans (23%; OR, 1.63; 95% CI, 1.61-1.64), and those with medical comorbidities (asthma or chronic obstructive pulmonary disease: 33%; OR, 4.03 [95% CI, 4.00-4.06]; schizophrenia: 4%; OR, 5.14 [95% CI, 5.05-5.22]; depression: 42%; OR, 3.10 [95% CI, 3.08-3.13]; and alcohol abuse: 20%; OR, 4.54 [95% CI, 4.50-4.59]) were more likely to be high risk (n = 351 012). Most (308 433 [88%]) high-risk veterans were assigned to general primary care; the remaining 12% (42 579 of 363 561) were assigned to specialized primary care (eg, women's health and homelessness). High-risk patients assigned to general primary care had more frequent primary care visits (mean [SD], 6.9 [6.5] per year) than those assigned to specialized primary care (mean [SD], 6.3 [7.3] per year; P < .001). They also had more medical specialty care visits (mean [SD], 4.4 [5.9] vs 3.7 [5.4] per year; P < .001) and fewer mental health visits (mean [SD], 9.0 [21.6] vs 11.3 [23.9] per year; P < .001). Use of intensive supplementary outpatient services was low overall. CONCLUSIONS AND RELEVANCE The findings suggest that, in integrated health care systems, approaches to support high-risk patient care should be embedded within general primary care and mental health care if they are to improve outcomes for high-risk patient populations.
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Affiliation(s)
- Evelyn T. Chang
- Center for the Study of Healthcare Innovation, Implementation and Policy, Veterans Affairs (VA) Greater Los Angeles Healthcare System, Los Angeles, California
- Division of General Internal Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California
- Division of General Internal Medicine, David Geffen School of Medicine at UCLA (University of California at Los Angeles), Los Angeles
| | - Donna M. Zulman
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California
| | - Karin M. Nelson
- Seattle-Denver Health Services Research & Development Center of Innovation, VA Puget Sound Healthcare System, Seattle, Washington
- General Internal Medicine Service, VA Puget Sound Healthcare System, Seattle, Washington
- Department of Medicine, University of Washington, Seattle
- Department of Health Services, University of Washington, Seattle
| | - Ann-Marie Rosland
- VA Pittsburgh Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania
- Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - David A. Ganz
- Center for the Study of Healthcare Innovation, Implementation and Policy, Veterans Affairs (VA) Greater Los Angeles Healthcare System, Los Angeles, California
- VA Greater Los Angeles Geriatric Research, Education and Clinical Center, Los Angeles, California
- UCLA Multicampus Program in Geriatric Medicine and Gerontology, Los Angeles, California
| | - Stephan D. Fihn
- Department of Medicine, University of Washington, Seattle
- Department of Health Services, University of Washington, Seattle
| | - Rebecca Piegari
- VA Office of Clinical Systems Development & Evaluation, Washington, DC
| | - Lisa V. Rubenstein
- Division of General Internal Medicine, David Geffen School of Medicine at UCLA (University of California at Los Angeles), Los Angeles
- Fielding School of Public Health, UCLA, Los Angeles, California
- RAND Corporation, Santa Monica, California
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McCarthy J, Bianchi A. Implementation of an intimate partner violence screening program in a university health care clinic. JOURNAL OF AMERICAN COLLEGE HEALTH : J OF ACH 2020; 68:444-452. [PMID: 30908149 DOI: 10.1080/07448481.2019.1577864] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 12/17/2018] [Accepted: 01/21/2019] [Indexed: 06/09/2023]
Abstract
Objectives: To examine whether an intimate partner violence (IPV) screening program is related to a positive change in health care providers' knowledge, attitudes, and self-efficacy of IPV screening. Participants: Eleven health care providers at a university health care clinic participated in the IPV screening program. Methods: A one-group pretest-posttest design was used to examine whether an IPV screening program was related to a change in health care providers' knowledge, attitudes, and self-efficacy of IPV screening. Results: Findings indicated that there was a significant difference (p < 000) between the posttest scores and the pretest scores on the Domestic Violence Healthcare Provider Survey Scale. Domain analysis of the scale revealed a significant difference in perceived self-efficacy (p = .001), system support (p = <.002), victim provider safety (p = .015), and beliefs of blaming victims (p = <.004). No statistical difference was found in professional role resistance/fear of offending (p = .158). Conclusions: A university health care clinic IPV screening program was related to a positive change in health care providers' knowledge, attitudes, and self-efficacy of IPV screening.
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Affiliation(s)
- Jessica McCarthy
- University of Louisiana at Lafayette, Lafayette, LA, USA
- Minute Med Walk-In Clinic, Lafayette, LA, USA
| | - Ann Bianchi
- College of Nursing, The University of Alabama in Huntsville, Huntsville, AL, USA
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Than C, Chuang E, Washington DL, Needleman J, Canelo I, Meredith LS, Yano EM. Understanding Gender Sensitivity of the Health Care Workforce at the Veterans Health Administration. Womens Health Issues 2020; 30:120-127. [PMID: 32094056 DOI: 10.1016/j.whi.2020.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 12/23/2019] [Accepted: 01/06/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Gender sensitivity of providers and staff has assumed increasing importance in closing historical gender disparities in health care quality and outcomes. The Department of Veterans Affairs (VA) has implemented several initiatives intended to improve gender sensitivity of its health care workforce. The current study examines practice- and individual-level characteristics associated with gender sensitivity of primary care providers (PCPs) and staff. METHODS We surveyed PCPs and staff (nurses, medical assistants, and clerks) at 12 VA medical centers (VAMCs) (n = 256 of 649; response rate, 39%). Gender sensitivity was measured using a 10-item scale adapted from the Gender Awareness Inventory-VA. We used weighted multivariate regression with maximum likelihood estimation to identify individual- and practice-level characteristics associated with gender sensitivity of PCPs and staff. RESULTS PCPs and staff had similar gender sensitivity but differed in most characteristics associated with that gender sensitivity. Among PCPs, women's health training and positive communication with others in the clinic were associated with greater gender sensitivity. For staff, prior work experience caring for women, working in Women's Health Patient-Aligned Care Teams, and rural location were associated with greater gender sensitivity, whereas more years of VA service was associated with lower gender sensitivity. Working at VA medical centers with a higher volume of women veteran patients was associated with greater gender sensitivity for both PCPs and staff. CONCLUSIONS Women's health training and experience in working with other women's health professionals are strongly correlated with greater gender sensitivity in the clinical workforce.
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Affiliation(s)
- Claire Than
- VA Health Services Research & Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California; Department of Health Policy and Management, Fielding School of Public Health, University of California Los Angeles (UCLA), Los Angeles, California
| | - Emmeline Chuang
- Department of Health Policy and Management, Fielding School of Public Health, University of California Los Angeles (UCLA), Los Angeles, California
| | - Donna L Washington
- VA Health Services Research & Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California; Department of Medicine, Geffen School of Medicine, UCLA, Los Angeles, California
| | - Jack Needleman
- Department of Health Policy and Management, Fielding School of Public Health, University of California Los Angeles (UCLA), Los Angeles, California
| | - Ismelda Canelo
- VA Health Services Research & Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | | | - Elizabeth M Yano
- VA Health Services Research & Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California; Department of Health Policy and Management, Fielding School of Public Health, University of California Los Angeles (UCLA), Los Angeles, California.
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6
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Danitz SB, Stirman SW, Grillo AR, Dichter ME, Driscoll M, Gerber MR, Gregor K, Hamilton AB, Iverson KM. When user-centered design meets implementation science: integrating provider perspectives in the development of an intimate partner violence intervention for women treated in the United States' largest integrated healthcare system. BMC Womens Health 2019; 19:145. [PMID: 31771557 PMCID: PMC6880505 DOI: 10.1186/s12905-019-0837-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 10/31/2019] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Intimate partner violence (IPV) against women is a global health problem that is a substantial source of human suffering. Within the United States (US), women veterans are at high risk for experiencing IPV. There is an urgent need for feasible, acceptable, and patient-centered IPV counseling interventions for the growing number of women treated in the US's largest integrated healthcare system, the Veterans Health Administration (VHA). Implementation science and user-centered-design (UCD) can play an important role in accelerating the research-to-practice pipeline. Recovering from IPV through Strengths and Empowerment (RISE) is a flexible, patient-centered, modular-based program that holds promise as a brief counseling intervention for women veterans treated in VHA. We utilized a UCD approach to develop and refine RISE (prior to formal effectiveness evaluations) by soliciting early feedback from the providers where the intervention will ultimately be implemented. The current study reports on the feedback from VHA providers that was used to tailor and refine RISE. METHOD We conducted and analyzed semi-structured, key-informant interviews with VHA providers working in clinics relevant to the delivery of IPV interventions (n = 23) at two large medical centers in the US. Participants' mean age was 42.6 years (SD = 11.6), they were predominately female (91.3%) and from a variety of relevant disciplines (39.1% psychologists, 21.7% social workers, 17.4% physicians, 8.7% registered nurses, 4.3% psychiatrists, 4.3% licensed marriage and family therapists, 4.3% peer specialists). We conducted rapid content analysis using a hybrid inductive-deductive approach. RESULTS Providers perceived RISE as highly acceptable and feasible, noting strengths including RISE's structure, patient-centered agenda, and facilitation of provider comfort in addressing IPV. Researchers identified themes related to content and context modifications, including requests for additional safety check-ins, structure for goal-setting, and suggestions for how to develop and implement RISE-specific trainings. CONCLUSIONS These findings have guided refinements to RISE prior to formal effectiveness testing in VHA. We discuss implications for the use of UCD in intervention development and refinement for interventions addressing IPV and other trauma in health care settings globally. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT03261700; Date of registration: 8/25/2017, date of enrollment of first participant in trial: 10/22/2018. Unique Protocol ID: IIR 16-062.
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Affiliation(s)
- Sara B. Danitz
- Women’s Health Sciences Division of the National Center for PTSD (116B-3), VA Boston Healthcare System, 150 South Huntington Avenue, Boston, MA 02130 USA
| | - Shannon Wiltsey Stirman
- Dissemination and Training Division of the National Center for PTSD, VA Palo Alto Healthcare System, Menlo Park, CA USA
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, CA USA
| | - Alessandra R. Grillo
- Women’s Health Sciences Division of the National Center for PTSD (116B-3), VA Boston Healthcare System, 150 South Huntington Avenue, Boston, MA 02130 USA
| | - Melissa E. Dichter
- VA Center for Health Equity Research and Promotion (CHERP), Philadelphia, PA USA
- Temple University, School of Social Work, Philadelphia, PA USA
| | - Mary Driscoll
- Pain Research, Informatics, Multi-morbidities, and Education (PRIME), VA Connecticut Healthcare System, West Haven, CT USA
- Yale School of Medicine, New Haven, CT USA
| | - Megan R. Gerber
- VA Boston Healthcare System, Boston, MA USA
- Boston University School of Medicine, Boston, MA USA
| | - Kristin Gregor
- VA Boston Healthcare System, Boston, MA USA
- Boston University School of Medicine, Boston, MA USA
| | - Alison B. Hamilton
- VA Center for the Study of Healthcare Innovation, Implementation and Policy, Los Angeles, CA USA
- UCLA Department of Psychiatry and Biobehavioral Sciences, Los Angeles, CA USA
| | - Katherine M. Iverson
- Women’s Health Sciences Division of the National Center for PTSD (116B-3), VA Boston Healthcare System, 150 South Huntington Avenue, Boston, MA 02130 USA
- Department of Psychiatry, Boston University School of Medicine, Boston, MA USA
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7
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Iverson KM, Sorrentino AE, Bellamy SL, Grillo AR, Haywood TN, Medvedeva E, Roberts CB, Dichter ME. Adoption, penetration, and effectiveness of a secondary risk screener for intimate partner violence: Evidence to inform screening practices in integrated care settings. Gen Hosp Psychiatry 2018; 51:79-84. [PMID: 29353128 DOI: 10.1016/j.genhosppsych.2018.01.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 01/05/2018] [Accepted: 01/08/2018] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Veterans Health Administration (VHA) has implemented screening for past-year intimate partner violence (IPV) in some healthcare facilities along with secondary screening of risk for severe violence among those screening positive in order to facilitate follow-up care for high-risk patients. We evaluated the adoption, penetration, and effectiveness of secondary screening as a tool to facilitate timely follow-up services. METHODS Retrospective review of medical records (screening and healthcare use) of 774 women screening positive for past-year IPV (IPV+) at 11 facilities nationwide from April 2014-April 2016. Chi-square and t-tests examined factors related to secondary screening. RESULTS Three of eleven (27.3%) facilities that implemented primary IPV screening adopted secondary screening. At adopting sites, 56.4% eligible (i.e., IPV+) women received secondary screening. Among 185 IPV+ women who completed secondary screening, 33.0% screened positive for severe IPV. Screening positive during secondary screening was associated with higher rate of psychosocial care within 60 days (73.8% vs. 54.0% of IPV+ patients screening negative; p < .05), posttraumatic stress disorder diagnosis (31.1% vs. 15.3%; p < .05), and being physically threatened or harmed (>50% vs. <15%; p < .001). CONCLUSIONS Secondary risk assessment following IPV screening may expedite access to psychosocial follow-up care in integrated healthcare settings. However, program uptake needs to be enhanced.
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Affiliation(s)
- Katherine M Iverson
- Women's Health Sciences Division of the National Center for PTSD, VA Boston Healthcare System, Boston, MA, United States; Department of Psychiatry, Boston University School of Medicine, Boston, MA, United States.
| | - Anneliese E Sorrentino
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, United States
| | - Scarlett L Bellamy
- Department of Epidemiology and Biostatistics, Drexel University Dornsife School of Public Health, Philadelphia, PA, United States
| | - Alessandra R Grillo
- Women's Health Sciences Division of the National Center for PTSD, VA Boston Healthcare System, Boston, MA, United States
| | - Terri N Haywood
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, United States
| | - Elina Medvedeva
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, United States
| | - Christopher B Roberts
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, United States
| | - Melissa E Dichter
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, United States; Department of Family Medicine and Community Health, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
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