Mixed-Methods Study of Uptake of the Extension for Community Health Outcomes (ECHO) Telemedicine Model for Rural Veterans With HIV

Interventions to improve primary healthcare in rural settings: A scoping review

BACKGROUND

Residents of rural areas have poorer health status, less healthy behaviours and higher mortality than urban dwellers, issues which are commonly addressed in primary care. Strengthening primary care may be an important tool to improve the health status of rural populations.

OBJECTIVE

Synthesize and categorize studies that examine interventions to improve rural primary care.

ELIGIBILITY CRITERIA

Experimental or observational studies published between January 1, 1996 and December 2022 that include an historical or concurrent control comparison.

SOURCES OF EVIDENCE

Pubmed, CINAHL, Cochrane Library, Embase.

CHARTING METHODS

We extracted and charted data by broad category (quality, access and efficiency), study design, country of origin, publication year, aim, health condition and type of intervention studied. We assigned multiple categories to a study where relevant.

RESULTS

372 papers met our inclusion criteria, divided among quality (82%), access (20%) and efficiency (13%) categories. A majority of papers were completed in the USA (40%), Australia (15%), China (7%) or Canada (6%). 35 (9%) papers came from countries in Africa. The most common study design was an uncontrolled before-and-after comparison (32%) and only 24% of studies used randomized designs. The number of publications each year has increased markedly over the study period from 1-2/year in 1997-99 to a peak of 49 papers in 2017.

CONCLUSIONS

Despite substantial inequity in health outcomes associated with rural living, very little attention is paid to rural primary care in the scientific literature. Very few studies of rural primary care use randomized designs.

Personalized Intervention to Improve Medication Adherence for Persons with Multiple Sclerosis

Purpose

To evaluate the acceptability, retention, and efficacy of face-to-face intervention, incorporating education and Motivational Interviewing (MI) to support persons with relapsing-remitting multiple sclerosis (PwRRMS) and increase self-reported medication adherence.

Patients and Methods

PwRRMS (N = 60) prescribed Disease Modifying Treatment (DMT), who were identified as non-adherent and consented to participate in an intervention, received verbal education and counseling from their treating physician, a tailored MI counseling and a booster session via telephone with a health psychologist, and a concluding MI counseling six months later. Each PwRRMS filled a battery of patient-reported outcomes (PROs) at baseline, six and 12 months later. The design was a quasi-experimental pre-test post-test across a year.

Results

Of the sixty identified persons who consented to enroll, 52 completed the intervention and 46 completed the follow-up. At six months following the baseline, adherence scores increased (median = 12.0) and were significantly different than at baseline (median=10.0, p = 0.030). Still, at 12 months follow-up there was no significant difference from baseline in reported adherence (median = 11.0, p = 0.106).

Conclusion

This study demonstrated reasonable retention and initial efficacy of a combined psycho-education and MI protocol for PwRRMS to enhance medication adherence to DMT. To maintain the change, a more sustained intervention is required.

Urban-rural disparities in geographic accessibility to care for people living with HIV

In the United States, people living with HIV (PLWH) in rural areas fare worse along the HIV care continuum than their urban counterparts; this may be due in part to limited geographic access to care. We estimated drive time to care for PLWH, focusing on urban-rural differences. Adult Medicaid enrollees living with HIV and their usual care clinicians were identified using administrative claims data from 14 states (Medicaid Analytic eXtract, 2009-2012). We used geographic network analysis to calculate one-way drive time from the enrollee's ZIP code tabulation area centroid to their clinician's practice address, then examined urban-rural differences using bivariate statistics. Additional analyses included altering the definition of rurality; examining subsamples based on the state of residence, services received, and clinician specialty; and adjusting for individual and county characteristics. Across n = 49,596 PLWH, median drive time to care was 12.8 min (interquartile range 26.3). Median drive time for rural enrollees (43.6 (82.0)) was nearly four times longer than for urban enrollees (11.9 (20.6) minutes, p < 0.0001), and drive times exceeded one hour for 38% of rural enrollees (versus 12% of urban, p < 0.0001). Urban-rural disparities remained in all additional analyses. Sustained efforts to circumvent limited geographic access to care are critical for rural areas.

Design and methods of a randomized trial testing "Advancing care for COPD in people living with HIV by implementing evidence-based management through proactive E-consults (ACHIEVE)"

Chronic obstructive pulmonary disease (COPD) is one of the most common comorbid diseases among aging people with HIV (PWH) and is often mismanaged. To address this gap, we are conducting the study, "Advancing care for COPD in people living with HIV by Implementing Evidence-based management through proactive E-consults (ACHIEVE)." This intervention optimizes COPD management by promoting effective, evidence-based care and de-implementing inappropriate therapies for COPD in PWH receiving care at Veteran Affairs (VA) medical centers. Study pulmonologists are proactively supporting ID providers managing a population of PWH who have COPD, offering real-time evidence-based recommendations tailored to each patient. We are leveraging VA clinical and informatics infrastructures to communicate recommendations between the study team and clinical providers through the electronic health record (EHR) as an E-consult. If effective, ACHIEVE could serve as a model of effective, efficient COPD management among PWH receiving care in VA. This paper outlines the rationale and methodology of the ACHIEVE trial, one of a series of studies funded by the National Heart, Lung, and Blood Institute (NHLBI) within the ImPlementation REsearCh to DEvelop Interventions for People Living with HIV (PRECluDE) consortium to study chronic disease comorbidities in HIV populations.

Building communities of practice through case-based e-learning to prevent and manage TB among people living with HIV-India

BACKGROUND

Co-management of HIV-TB coinfection remains a challenge globally. Addressing TB among people living with HIV (PLHIV) is a key priority for the Government of India (GoI). In 2016, GoI implemented single-window services to prevent and manage TB in PLHIV. To strengthen HIV-TB service delivery, case-based e-learning was introduced to health care providers at Antiretroviral Therapy centres (ARTc).

METHODS

We implemented a hub and spoke model to deliver biweekly, virtual, case-based e-learning at select ARTc (n = 115), from four states of India-Delhi, Uttar Pradesh, Andhra Pradesh and Tamil Nadu. We evaluated feasibility and acceptability of case-based e-learning and its impact on professional satisfaction, self-efficacy, knowledge retention using baseline and completion surveys, session feedback, pre-and post-session assessments. We reviewed routine programmatic data and patient outcomes to assess practices among participating ARTc.

RESULTS

Between May 2018 and September 2020, 59 sessions were conducted with mean participation of 55 spokes and 152 participants. For 95% and 88% of sessions ≥ 80% of respondents agreed that topics were clear and relevant to practice, and duration of session was appropriate, respectively. Session participants significantly improved in perceived knowledge, skills and competencies (+ 8.6%; p = 0.025), and technical knowledge (+ 18.3%; p = 0.04) from baseline. Participating ARTc increased TB screening (+ 4.2%, p < 0.0001), TB diagnosis (+ 2.7%, p < 0.0001), ART initiation (+ 4.3%, p < 0.0001) and TB preventive treatment completion (+ 5.2%, p < 0.0001).

CONCLUSION

Case-based e-learning is an acceptable and effective modus of capacity building and developing communities of practice to strengthen integrated care. E-learning could address demand for accessible and sustainable continuing professional education to manage complex diseases, and thereby enhance health equity. We recommend expansion of this initiative across the country for management of co-morbidities as well as other communicable and non-communicable diseases to augment the existing capacity building interventions by provide continued learning and routine mentorship through communities of practice.

Risk Factors for COVID-19 Mortality Among People Living with HIV: A Scoping Review

People living with HIV (PLWH) are particularly vulnerable to worsened outcomes of COVID-19. Therefore, the purpose of this work was to provide a scoping review of the literature to assess the risk factors for COVID-19 mortality among PLWH. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR), searches were conducted in PubMed, Scopus, Global Health, and WHO Coronavirus Database. Articles were eligible for inclusion if they were in English, included PLWH who died after COVID-19 infection, and described risk factors for mortality. Results were descriptively synthesized and pooled thereafter. Study quality was assessed using the Joanna Brigg Institute's critical appraisal tools. 20 studies were eligible for inclusion, with the pooled death rate being 11.7%. Age was a major risk factor, especially after 50 (23.2%) and after 70 (41.8%), and males had a death rate nearly double that of females. As total comorbidities increased, the death rate also greatly increased; among those with comorbidities, the highest fatality rates were those with cardiovascular disease (30.2%), chronic kidney disease (23.5%), obesity (22.4%), and diabetes (18.4%). Other risk factors for mortality among PLWH included having a Black racial background, being an injection drug user, being a smoker, and having a CD4 cell count below 200. There is a need to better study confounding factors, and to understand how vaccination influences mortality risk. Overall, the findings highlight a need to ensure that focus is placed on the varying demographics of PLWH amidst COVID-19 control efforts.

Qualitative Study of Health Care Providers' Uptake of the Project Extension for Community Health Outcomes for Chronic Pain

INTRODUCTION

There is an enormous need for pain education among all health care professions before and after licensure. The study goal was to explore generic and chronic pain-specific factors that influenced uptake of a continuous education program for chronic pain, the Project Extension for Community Health Outcomes (ECHO) CHUM Douleur chronique.

METHODS

The study team conducted 20 semistructured virtual interviews among participants of the program. Interviews were transcribed verbatim, and two analysts used a reflexive thematic analysis approach to generate study themes.

RESULTS

Five aspects facilitating engagement, continued participation, and uptake of the Project ECHO were identified: rapid access to reliable information, appraising one's knowledge, cultivating meaningful relationships, breaking the silos of learning and practice, and exponential possibilities of treatment orchestrations for a complex condition with no cure. Although participants' experiences of the program was positive overall, some obstacles to engagement and continued participation were identified: heterogeneity of participants' profiles, feelings of powerlessness and discouragement in the face of complex incurable pain conditions, challenges in applying recommendations, medical hierarchy, and missed opportunity for advocacy.

DISCUSSION

Many disease-specific and contextual factors contributed to an increased motivation to participate in the ECHO program. Some elements, such as the complexity of diagnosis and treatment, and the multidisciplinary requirements to manage cases were identified as elements motivating one's participation in the program but also acting as a barrier to knowledge uptake. These must be understood in the broader systemic challenges of the current health care system and lack of resources to access allied health care.

Support Models for Addiction Related Treatment (SMART) for pregnant women: Study protocol of a cluster randomized trial of two treatment models for opioid use disorder in prenatal clinics

Introduction

The prevalence of opioid use disorder (OUD) in pregnancy increased nearly five-fold over the past decade. Despite this, obstetric providers are less likely to treat pregnant women with medication for OUD than non-obstetric providers (75% vs 91%). A major reason is many obstetricians feel unprepared to prescribe medication for opioid use disorder (MOUD). Education and support may increase prescribing and overall comfort in delivering care for pregnant women with OUD, but optimal models of education and support are yet to be determined.

Methods and analysis

We describe the rationale and conduct of a matched-pair cluster randomized clinical trial to compare the effectiveness of two models of support for reproductive health clinicians to provide care for pregnant and postpartum women with OUD. The primary outcomes of this trial are patient treatment engagement and retention in OUD treatment. This study compares two support models: 1) a collaborative care approach, based upon the Massachusetts Office-Based-Opioid Treatment Model, that provides practice-level training and support to providers and patients through the use of care managers, versus 2) a telesupport approach based on the Project Extension for Community Healthcare Outcomes, a remote education model that provides mentorship, guided practice, and participation in a learning community, via video conferencing.

Discussion

This clustered randomized clinical trial aims to test the effectiveness of two approaches to support practitioners who care for pregnant women with an OUD. The results of this trial will help determine the best model to improve the capacity of obstetrical providers to deliver treatment for OUD in prenatal clinics.

Trial registration

Clinicaltrials.gov trial registration number: NCT0424039.

Telehealth Interventions and Outcomes Across Rural Communities in the United States: Narrative Review

Background

In rural communities, there are gaps in describing the design and effectiveness of technology interventions for treating diseases and addressing determinants of health.

Objective

The aim of this study is to evaluate literature on current applications, therapeutic areas, and outcomes of telehealth interventions in rural communities in the United States.

Methods

A narrative review of studies published on PubMed from January 2017 to December 2020 was conducted. Key search terms included telehealth, telemedicine, rural, and outcomes.

Results

Among 15 included studies, 9 studies analyzed telehealth interventions in patients, 3 in health care professionals, and 3 in both patients and health care professionals. The included studies reported positive outcomes and experiences of telehealth use in rural populations including acceptability and increased satisfaction; they also noted that technology is convenient and efficient. Other notable benefits included decreased direct and indirect costs to the patient (travel cost and time) and health care service provider (staffing), lower onsite health care resource utilization, improved physician recruitment and retention, improved access to care, and increased education and training of patients and health care professionals.

Conclusions

Telehealth models were associated with positive outcomes for patients and health care professionals, suggesting these models are feasible and can be effective. Future telehealth interventions and studies examining these programs are warranted, especially in rural communities, and future research should evaluate the impact of increased telehealth use as a result of the COVID-19 pandemic.

Opioid Use Disorder ECHO: A Program Evaluation of a Project That Provides Knowledge and Builds Capacity for Community Health Workers in Medically Underserved Areas of South Texas

Opioid use disorder is a growing public health concern in South Texas. To assist in mitigating the effects of this epidemic, staff produced a program that focused on replicating, modifying, and evaluating the impact of the "Opioid Addiction Treatment ECHO™ (Extension of Community Health Outcomes) for CHWs (community health workers) program" on 26 CHWs practicing in rural and other medically underserved areas through teleconferencing technology. CHWs trained on the topic of substance use disorder concentrated on behavioral health integration with a focus on opioid prescription misuse. The analysis found that knowledge attainment was increased above the pretest means. The ECHO™ model proved to be effective at linking subject matter experts and specialists at an academic "hub" with CHWs in local communities.

Integration of telehealth services in the healthcare system: with emphasis on the experience of patients living with HIV

The US Health Resources and Services Administration defines telehealth as the use of electronic information and telecommunications technologies to support long-distance clinical healthcare, patient and professional health-related education, public health and health administration. Many studies have supported the use of telehealth to increase convenience to patients, improve patient satisfaction, diminish healthcare disparities, and reduce cost that will ultimately lead to improvement in clinical outcomes and quality of care. However, guaranteeing confidentiality, educating patients and providers, and obtaining insurance reimbursement are some of the challenges that face the implementation of telehealth program. The use of telehealth has been investigated in acute infections, such as endocarditis and chronic infections as in hepatitis C, and HIV. The purpose of this review is to focus on the use of telehealth services for people living with HIV (PLWH). For PLWH, telehealth could be particularly useful by connecting specialty providers to an underserved population and addressing many of the factors identified as barriers to HIV care. To date, the literature supports the use of telehealth for the management of chronic diseases including HIV. Most of the studies showed a high acceptability and positive experience with telehealth services among PLWH. However, fewer studies have evaluated telemedicine for chronic direct care of PLWH. Well-designed studies are needed to show that the implementation of telehealth could improve the HIV care continuum. In addition, future research should focus on identifying the group of patients that could benefit the most from such intervention.

Implementing Treatment of Opioid-Use Disorder in Rural Settings: a Focus on HIV and Hepatitis C Prevention and Treatment

PURPOSE OF REVIEW

To describe the epidemiology of opioid-use disorder in the rural United States (U.S.) as it pertains to HIV and hepatitis C transmission and treatment resources.

RECENT FINDINGS

Heroin and fentanyl analogs have surpassed prescription opioids in their availability in rural opioid markets adding to HIV and hepatitis C (HCV) and overdose risks. Only 18% of rural individuals live in towns with inpatient services which are of limited quality and utility. Opioid treatment programs that provide methadone are not located in rural areas and only 3% of the primary care providers have the ability to prescribe buprenorphine. National models and resources have been established but lack implementation in rural areas leading to ongoing HIV and HCV transmission and overdose. Addressing the adverse impact of opioids in the rural U.S. will require a concerted effort to implement effective treatments according to national standards.

The California Multidrug-Resistant Tuberculosis Consult Service: a partnership of state and local programs

Background: The US Centers for Disease Control and Prevention recommend expert consultation for multi-drug-resistant tuberculosis (MDR-TB) cases. In 2002, the California MDR-TB Service was created to provide expert MDR-TB consultations. We describe the characteristics, treatment outcomes and management of patients referred to the Service. Methods: Surveillance data were used for descriptive analysis of cases, with consultation during July 2002-December 2012. Clinical consultation data and modified World Health Organization indicators were used to assess the care and management of cases, with consultation from January 2009 to December 2012. Results: Of 339 MDR-TB patients, 140 received a consultation. The proportion of patients receiving a consultation increased from 12% in 2002 to 63% in 2012. There were 24 pre-extensively drug-resistant TB and 5 patients with extensively drug-resistant TB. The majority (n = 123, 88%) completed treatment, 5 (4%) died, 7 (5%) moved before treatment completion, 4 (3%) stopped treatment due to an adverse event and 1 (1%) had an unknown outcome. Indicator data showed that 86% underwent rapid molecular drug susceptibility testing, 98% received at least four drugs to which they had known or presumed susceptibility, and 93% culture converted within 6 months. Conclusions: Consultations with the MDR-TB Service increased over time. Results highlight successful treatment and indicator outcomes.

Research Agenda for Antimicrobial Stewardship in the Veterans Health Administration

Antimicrobial stewardship is vital to reducing the spread of antimicrobial resistance. A group of investigators and clinicians within the Veterans Health Administration set forth a research agenda for antimicrobial stewardship, including research targets for inpatient and outpatient stewardship activities, metrics, and antimicrobial dosing and duration.

The Continuum of HIV Care in Rural Communities in the United States and Canada: What Is Known and Future Research Directions

The nature of the HIV epidemic in the United States and Canada has changed with a shift toward rural areas. Socioeconomic factors, geography, cultural context, and evolving epidemics of injection drug use are coalescing to move the epidemic into locations where populations are dispersed and health care resources are limited. Rural-urban differences along the care continuum demonstrate the implications of this sociogeographic shift. Greater attention is needed to build a more comprehensive understanding of the rural HIV epidemic in the United States and Canada, including research efforts, innovative approaches to care delivery, and greater community engagement in prevention and care.