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Patel MS, Fogel R, Winegar AL, Horseman C, Ottenbacher A, Habash S, Dukes JL, Brinson TC, Price SC, Masoudi FA, Cacchione J, Yehia BR. Effect of Text Message Reminders and Vaccine Reservations on Adherence to a Health System COVID-19 Vaccination Policy: A Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2222116. [PMID: 35857327 PMCID: PMC9301516 DOI: 10.1001/jamanetworkopen.2022.22116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Many organizations implemented COVID-19 vaccination requirements during the pandemic, but the best way to increase adherence to these policies is unknown. OBJECTIVE To evaluate if behavioral nudges delivered through text messages could accelerate adherence to a health system's COVID-19 vaccination policy. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial was conducted within Ascension health system from October 11 to November 8, 2021. Participants included health system employees in the Midwest or South US who were not adherent with the vaccination policy 1 month before its deadline. Data were analyzed from November 17, 2021, to February 25, 2022. INTERVENTIONS Participants were randomly assigned to control or to receive a text message intervention that stated a vaccine had been reserved for the participant, with a scheduled date for vaccination within a 2-week period. Participants could reschedule to a different date within the period or upload a copy of their vaccination card. Follow-up text message reminders were sent the day before and the day of the appointment. MAIN OUTCOMES AND MEASURES The primary outcome was adherence to the health system's vaccination policy during the 2-week intervention. Secondary outcomes included time to vaccination during a 4-week follow-up period. RESULTS The sample included 2000 participants (mean [SD] age, 36.4 [12.3] years; 1724 [86.2%] women), with 1000 participants randomized to the control group and 1000 participants randomized to the intervention group. Overall, there were 164 Hispanic participants (8.2%), 46 non-Hispanic Asian participants (2.3%), 202 non-Hispanic Black participants (10.1%), and 1418 non-Hispanic White participants (70.9%). By the end of the 2-week intervention, 363 participants in the text message nudge group (36.3%) and 318 participants in the control group (31.8%) were adherent with the vaccination policy, representing a significant increase of 4.9 (95% CI, 0.8 to 9.1) percentage points in adjusted analyses comparing the nudge group with the control group (P = .02). Among participants who became adherent by the end of the 4-week follow-up period, the text message nudge significantly reduced time to adherence by a mean of 2.4 (95% CI, 2.1 to 4.7) days (P < .001) and a median of 5.0 (95% CI, 2.5 to 7.7) days (P < .001) compared with the control group. At 4 weeks, overall vaccination adherence was no longer different between groups (control: 477 participants [47.7%]; intervention: 472 participants [47.2%]). CONCLUSIONS AND RELEVANCE This randomized clinical trial found that a behavioral nudge delivered through text messages accelerated adherence to a health system's COVID-19 vaccination policy but did change overall adherence by the time of the policy deadline. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT05037201.
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Elliott T, Yehia BR, Winegar AL, Raja JK, Jones A, Shockley E, Cacchione J. Analysis of COVID-19 vaccine non-intent by essential vs non-essential worker, demographic, and socioeconomic status among 101,048 US adults. PLoS One 2021; 16:e0258540. [PMID: 34710101 PMCID: PMC8553079 DOI: 10.1371/journal.pone.0258540] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 09/29/2021] [Indexed: 12/01/2022] Open
Abstract
As of May 2021, over 286 million coronavirus 2019 (COVID-19) vaccine doses have been administered across the country. This data is promising, however there are still populations that, despite availability, are declining vaccination. We reviewed vaccine likelihood and receptiveness to recommendation from a doctor or nurse survey responses from 101,048 adults (≥18 years old) presenting to 442 primary care clinics in 8 states and the District of Columbia. Occupation was self-reported and demographic information extracted from the medical record, with 58.3% (n = 58,873) responding they were likely to receive the vaccine, 23.6% (n = 23,845) unlikely, and 18.1% (n = 18,330) uncertain. We found that essential workers were 18% less likely to receive the COVID-19 vaccination. Of those who indicated they were not already “very likely” to receive the vaccine, a recommendation from a nurse or doctor resulted in 16% of respondents becoming more likely to receive the vaccine, although certain occupations were less likely than others to be receptive to recommendations. To our knowledge, this is the first study to look at vaccine intent and receptiveness to recommendations from a doctor or nurse across specific essential worker occupations, and may help inform future early phase, vaccine rollouts and public health measure implementations.
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Affiliation(s)
- Tania Elliott
- Clinical and Network Services, Ascension Health, Saint Louis, Missouri, United States of America
- * E-mail:
| | - Baligh R. Yehia
- Clinical and Network Services, Ascension Health, Saint Louis, Missouri, United States of America
| | - Angela L. Winegar
- Clinical and Network Services, Ascension Health, Saint Louis, Missouri, United States of America
- Ascension Data Science Institute, Saint Louis, Missouri, United States of America
| | - Jyothi Karthik Raja
- Clinical and Network Services, Ascension Health, Saint Louis, Missouri, United States of America
- Ascension Data Science Institute, Saint Louis, Missouri, United States of America
| | - Ashlin Jones
- Clinical and Network Services, Ascension Health, Saint Louis, Missouri, United States of America
- Ascension Data Science Institute, Saint Louis, Missouri, United States of America
| | - Erin Shockley
- Clinical and Network Services, Ascension Health, Saint Louis, Missouri, United States of America
- Ascension Data Science Institute, Saint Louis, Missouri, United States of America
| | - Joseph Cacchione
- Clinical and Network Services, Ascension Health, Saint Louis, Missouri, United States of America
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Affiliation(s)
| | - Stephan D Fihn
- Department of Medicine, University of Washington, Seattle
- Deputy Editor, JAMA Network Open
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Yehia BR, Winegar A, Fogel R, Fakih M, Ottenbacher A, Jesser C, Bufalino A, Huang RH, Cacchione J. Association of Race With Mortality Among Patients Hospitalized With Coronavirus Disease 2019 (COVID-19) at 92 US Hospitals. JAMA Netw Open 2020; 3:e2018039. [PMID: 32809033 PMCID: PMC7435340 DOI: 10.1001/jamanetworkopen.2020.18039] [Citation(s) in RCA: 225] [Impact Index Per Article: 56.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 07/14/2020] [Indexed: 12/11/2022] Open
Abstract
IMPORTANCE While current reports suggest that a disproportionate share of US coronavirus disease 2019 (COVID-19) cases and deaths are among Black residents, little information is available regarding how race is associated with in-hospital mortality. OBJECTIVE To evaluate the association of race, adjusting for sociodemographic and clinical factors, on all-cause, in-hospital mortality for patients with COVID-19. DESIGN, SETTING, AND PARTICIPANTS This cohort study included 11 210 adult patients (age ≥18 years) hospitalized with confirmed severe acute respiratory coronavirus 2 (SARS-CoV-2) between February 19, 2020, and May 31, 2020, in 92 hospitals in 12 states: Alabama (6 hospitals), Maryland (1 hospital), Florida (5 hospitals), Illinois (8 hospitals), Indiana (14 hospitals), Kansas (4 hospitals), Michigan (13 hospitals), New York (2 hospitals), Oklahoma (6 hospitals), Tennessee (4 hospitals), Texas (11 hospitals), and Wisconsin (18 hospitals). EXPOSURES Confirmed SARS-CoV-2 infection by positive result on polymerase chain reaction testing of a nasopharyngeal sample. MAIN OUTCOMES AND MEASURES Death during hospitalization was examined overall and by race. Race was self-reported and categorized as Black, White, and other or missing. Cox proportional hazards regression with mixed effects was used to evaluate associations between all-cause in-hospital mortality and patient characteristics while accounting for the random effects of hospital on the outcome. RESULTS Of 11 210 patients with confirmed COVID-19 presenting to hospitals, 4180 (37.3%) were Black patients and 5583 (49.8%) were men. The median (interquartile range) age was 61 (46 to 74) years. Compared with White patients, Black patients were younger (median [interquartile range] age, 66 [50 to 80] years vs 61 [46 to 72] years), were more likely to be women (2259 [49.0%] vs 2293 [54.9%]), were more likely to have Medicaid insurance (611 [13.3%] vs 1031 [24.7%]), and had higher median (interquartile range) scores on the Neighborhood Deprivation Index (-0.11 [-0.70 to 0.56] vs 0.82 [0.08 to 1.76]) and the Elixhauser Comorbidity Index (21 [0 to 44] vs 22 [0 to 46]). All-cause in-hospital mortality among hospitalized White and Black patients was 23.1% (724 of 3218) and 19.2% (540 of 2812), respectively. After adjustment for age, sex, insurance, comorbidities, neighborhood deprivation, and site of care, there was no statistically significant difference in risk of mortality between Black and White patients (hazard ratio, 0.93; 95% CI, 0.80 to 1.09). CONCLUSIONS AND RELEVANCE Although current reports suggest that Black patients represent a disproportionate share of COVID-19 infections and death in the United States, in this study, mortality for those able to access hospital care did not differ between Black and White patients after adjusting for sociodemographic factors and comorbidities.
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Affiliation(s)
| | - Angela Winegar
- Ascension Health, St Louis, Missouri
- Ascension Data Science Institute, St Louis, Missouri
| | | | | | - Allison Ottenbacher
- Ascension Health, St Louis, Missouri
- Ascension Data Science Institute, St Louis, Missouri
| | - Christine Jesser
- Ascension Health, St Louis, Missouri
- Ascension Clinical Research Institute, St Louis, Missouri
| | - Angelo Bufalino
- Ascension Health, St Louis, Missouri
- Ascension Data Science Institute, St Louis, Missouri
| | - Ren-Huai Huang
- Ascension Health, St Louis, Missouri
- Ascension Data Science Institute, St Louis, Missouri
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Meanley S, Yehia BR, Hines J, Thomas R, Calder D, Carter B, Dubé B, Bauermeister JA. HIV/AIDS-related stigma, immediate families, and proactive coping processes among a clinical sample of people living with HIV/AIDS in Philadelphia, Pennsylvania. J Community Psychol 2019; 47:1787-1798. [PMID: 31389625 DOI: 10.1002/jcop.22227] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 07/12/2019] [Accepted: 07/12/2019] [Indexed: 06/10/2023]
Abstract
People living with HIV/AIDS (PLWHA) engage in proactive coping behaviors to minimize the risk of interpersonal stigma. This study explores proactive coping processes in navigating HIV/AIDS-related stigma within immediate families. Data for this study come from 19 one-on-one, qualitative interviews with a diverse, clinical sample of PLWHA in Philadelphia, PA. Thematic analysis indicated that participants continue to experience enacted, anticipated, and internalized forms of HIV/AIDS-related stigma. Participants discussed status concealment and selective disclosure as proactive coping resulting from anticipated stigma and physical distancing as proactive coping motivated by internalized HIV/AIDS-related stigma. Study findings demonstrate how living with a stigmatized condition can affect PLWHA social interactions with close networks like immediate families, specifically in eliciting stigma-avoidant behaviors. Anti-stigma efforts that educate immediate families to overcome stigmatizing attitudes and provide HIV-positive family members with high-quality social support should be coupled with efforts that target health-promotive self-management strategies for PLWHA.
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Affiliation(s)
- Steven Meanley
- Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
- Program for Sexuality, Technology & Action Research, Philadelphia, Pennsylvania
- Center for Interdisciplinary Research on AIDS, Research Education Institute for Diverse Scholars, Yale University School of Public Health, New Haven, CT
| | - Baligh R Yehia
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Janet Hines
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Rosemary Thomas
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
- Penn Medicine Program for LGBT Health, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Daniel Calder
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
- Penn Medicine Program for LGBT Health, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Bryce Carter
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Benoit Dubé
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - José A Bauermeister
- Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
- Program for Sexuality, Technology & Action Research, Philadelphia, Pennsylvania
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McClain Z, Thomas R, Yehia BR. Sociocultural and Systemic Barriers to Health for Gender and Sexual Minority Populations. LGBT Health 2017. [DOI: 10.1891/9780826133786.0002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Lunn MR, Cui W, Zack MM, Thompson WW, Blank MB, Yehia BR. Sociodemographic Characteristics and Health Outcomes Among Lesbian, Gay, and Bisexual U.S. Adults Using Healthy People 2020 Leading Health Indicators. LGBT Health 2017; 4:283-294. [PMID: 28727950 DOI: 10.1089/lgbt.2016.0087] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
PURPOSE This study aimed to characterize the sociodemographic characteristics of sexual minority (i.e., gay, lesbian, bisexual) adults and compare sexual minority and heterosexual populations on nine Healthy People 2020 leading health indicators (LHIs). METHODS Using a nationally representative, cross-sectional survey (National Health Interview Survey 2013-2015) of the civilian, noninstitutionalized population (228,893,944 adults), nine Healthy People 2020 LHIs addressing health behaviors and access to care, stratified using a composite variable of sex (female, male) and sexual orientation (gay or lesbian, bisexual, heterosexual), were analyzed individually and in aggregate. RESULTS In 2013-2015, sexual minority adults represented 2.4% of the U.S. POPULATION Compared to heterosexuals, sexual minorities were more likely to be younger and to have never married. Gays and lesbians were more likely to have earned a graduate degree. Gay males were more likely to have a usual primary care provider, but gay/lesbian females were less likely than heterosexuals to have a usual primary care provider and health insurance. Gay males received more colorectal cancer screening than heterosexual males. Gay males, gay/lesbian females, and bisexual females were more likely to be current smokers than their sex-matched, heterosexual counterparts. Binge drinking was more common in bisexuals compared to heterosexuals. Sexual minority females were more likely to be obese than heterosexual females; the converse was true for gay males. Sexual minorities underwent more HIV testing than their heterosexual peers, but bisexual males were less likely than gay males to be tested. Gay males were more likely to meet all eligible LHIs than heterosexual males. Overall, more sexual minority adults met all eligible LHIs compared to heterosexual adults. Similar results were found regardless of HIV testing LHI inclusion. CONCLUSION Differences between sexual minorities and heterosexuals suggest the need for targeted health assessments and public health interventions aimed at reducing specific negative health behaviors.
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Affiliation(s)
- Mitchell R Lunn
- 1 Division of Nephrology, Department of Medicine, University of California , San Francisco, San Francisco, California.,2 The PRIDE Study/PRIDEnet, University of California , San Francisco, San Francisco, California.,3 Lesbian, Gay, Bisexual, and Transgender Medical Education Research Group, Stanford University School of Medicine , Stanford, California
| | - Wanjun Cui
- 4 Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, U.S. Centers for Disease Control and Prevention , Atlanta, Georgia
| | - Matthew M Zack
- 4 Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, U.S. Centers for Disease Control and Prevention , Atlanta, Georgia
| | - William W Thompson
- 5 Division of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, U.S. Centers for Disease Control and Prevention , Atlanta, Georgia
| | - Michael B Blank
- 6 Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania , Philadelphia, Pennsylvania.,7 Leonard Davis Institute of Health Economics, University of Pennsylvania , Philadelphia, Pennsylvania.,8 Annenberg Public Policy Center, Annenberg School for Communication, University of Pennsylvania , Philadelphia, Pennsylvania
| | - Baligh R Yehia
- 9 Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania , Philadelphia, Pennsylvania.,10 Penn Medicine Program for LGBT Health, University of Pennsylvania , Philadelphia, Pennsylvania
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8
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Eckstrand KL, Lunn MR, Yehia BR. Applying Organizational Change to Promote Lesbian, Gay, Bisexual, and Transgender Inclusion and Reduce Health Disparities. LGBT Health 2017; 4:174-180. [DOI: 10.1089/lgbt.2015.0148] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Kristen L. Eckstrand
- Department of Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Mitchell R. Lunn
- Division of Nephrology, Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Baligh R. Yehia
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Rebeiro PF, Abraham AG, Horberg MA, Althoff KN, Yehia BR, Buchacz K, Lau BM, Sterling TR, Gange SJ. Sex, Race, and HIV Risk Disparities in Discontinuity of HIV Care After Antiretroviral Therapy Initiation in the United States and Canada. AIDS Patient Care STDS 2017; 31:129-144. [PMID: 28282246 DOI: 10.1089/apc.2016.0178] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Disruption of continuous retention in care (discontinuity) is associated with HIV disease progression. We examined sex, race, and HIV risk disparities in discontinuity after antiretroviral therapy (ART) initiation among patients in North America. Adults (≥18 years of age) initiating ART from 2000 to 2010 were included. Discontinuity was defined as first disruption of continuous retention (≥2 visits separated by >90 days in the calendar year). Relative hazard ratio (HR) and times from ART initiation until discontinuity by race, sex, and HIV risk were assessed by modeling of the cumulative incidence function (CIF) in the presence of the competing risk of death. Models were adjusted for cohort site, baseline age, and CD4+ cell count within 1 year before ART initiation; nadir CD4+ cell count after ART, but before a study event, was assessed as a mediator. Among 17,171 adults initiating ART, median follow-up time was 3.97 years, and 49% were observed to have ≥1 discontinuity of care. In adjusted regression models, the hazard of discontinuity for patients was lower for females versus males [HR: 0.84; 95% confidence interval (CI): 0.79-0.89] and higher for blacks versus nonblacks (HR: 1.17; 95% CI: 1.12-1.23) and persons with injection drug use (IDU) versus non-IDU risk (HR: 1.33; 95% CI: 1.25-1.41). Sex, racial, and HIV risk differences in clinical retention exist, even accounting for access to care and known competing risks for discontinuity. These results point to vulnerable populations at greatest risk for discontinuity in need of improved outreach to prevent disruptions of HIV care.
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Affiliation(s)
- Peter F. Rebeiro
- Vanderbilt University School of Medicine, Department of Medicine, Division of Infectious Diseases, Nashville, Tennessee
| | - Alison G. Abraham
- Johns Hopkins University, Bloomberg School of Public Health, Department of Epidemiology, Baltimore, Maryland
| | - Michael A. Horberg
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, Maryland
| | - Keri N. Althoff
- Johns Hopkins University, Bloomberg School of Public Health, Department of Epidemiology, Baltimore, Maryland
| | - Baligh R. Yehia
- University of Pennsylvania, Perelman School of Medicine, Department of Medicine, Philadelphia, Pennsylvania
| | - Kate Buchacz
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Bryan M. Lau
- Johns Hopkins University, Bloomberg School of Public Health, Department of Epidemiology, Baltimore, Maryland
| | - Timothy R. Sterling
- Vanderbilt University School of Medicine, Department of Medicine, Division of Infectious Diseases, Nashville, Tennessee
| | - Stephen J. Gange
- Johns Hopkins University, Bloomberg School of Public Health, Department of Epidemiology, Baltimore, Maryland
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Agwu AL, Fleishman JA, Mahiane G, Nonyane BAS, Althoff KN, Yehia BR, Berry SA, Rutstein R, Nijhawan A, Mathews C, Aberg JA, Keruly JC, Moore RD, Gebo KA. Comparing longitudinal CD4 responses to cART among non-perinatally HIV-infected youth versus adults: Results from the HIVRN Cohort. PLoS One 2017; 12:e0171125. [PMID: 28182675 PMCID: PMC5300758 DOI: 10.1371/journal.pone.0171125] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Accepted: 01/15/2017] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Youth have residual thymic tissue and potentially greater capacity for immune reconstitution than adults after initiation of combination antiretroviral therapy (cART). However, youth face behavioral and psychosocial challenges that may make them more likely than adults to delay ART initiation and less likely to attain similar CD4 outcomes after initiating cART. This study compared CD4 outcomes over time following cART initiation between ART-naïve non-perinatally HIV-infected (nPHIV) youth (13-24 years-old) and adults (≥25-44 years-old). METHODS Retrospective analysis of ART-naïve nPHIV individuals 13-44 years-old, who initiated their first cART between 2008 and 2011 at clinical sites in the HIV Research Network. A linear mixed model was used to assess the association between CD4 levels after cART initiation and age (13-24, 25-34, 35-44 years), accounting for random variation within participants and between sites, and adjusting for key variables including gender, race/ethnicity, viral load, gaps in care (defined as > 365 days between CD4 tests), and CD4 levels prior to cART initiation (baseline CD4). RESULTS Among 2,595 individuals (435 youth; 2,160 adults), the median follow-up after cART initiation was 179 weeks (IQR 92-249). Baseline CD4 was higher for youth (320 cells/mm3) than for ages 25-34 (293) or 35-44 (258). At 239 weeks after cART initiation, median unadjusted CD4 was higher for youth than adults (576 vs. 539 and 476 cells/mm3, respectively), but this difference was not significant when baseline CD4 was controlled. Compared to those with baseline CD4 ≤200 cells/mm3, individuals with baseline CD4 of 201-500 and >500 cells/mm3 had greater predicted CD4 levels: 390, 607, and 831, respectively. Additionally, having no gaps in care and higher viral load were associated with better CD4 outcomes. CONCLUSIONS Despite having residual thymic tissue, youth attain similar, not superior, CD4 gains as adults. Early ART initiation with minimal delay is as essential to optimizing outcomes for youth as it is for their adult counterparts.
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Affiliation(s)
- Allison L. Agwu
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, United States of America
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States of America
| | - John A. Fleishman
- Center for Financing, Access, and Cost Trends, Agency for Healthcare Research and Quality, Rockville, MD, United States of America
| | - Guy Mahiane
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Bareng Aletta Sanny Nonyane
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Keri N. Althoff
- Bloomberg School of Public Health, Johns Hopkins Medical Institutions, Baltimore, MD, United States of America
| | - Baligh R. Yehia
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, United States of America
| | - Stephen A. Berry
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States of America
| | - Richard Rutstein
- Division of General Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, United States of America
| | - Ank Nijhawan
- Department of Internal Medicine, UT Southwestern Medical Center, Parkland Health and Hospital System, Dallas TX, United States of America
| | - Christopher Mathews
- Department of Medicine, University of California San Diego, San Diego, CA, United States of America
| | - Judith A. Aberg
- Department of Medicine, Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Jeanne C. Keruly
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States of America
| | - Richard D. Moore
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States of America
| | - Kelly A. Gebo
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States of America
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Abstract
Lesbian, gay, bisexual, transgender, queer and questioning (LGBTQ) youth may experience interpersonal and structural stigma within the health care environment. This article begins by reviewing special considerations for the care of LGBTQ youth, then turns to systems-level principles underlying inclusive and affirming care. It then examines specific strategies that individual providers can use to provide more patient-centered care, and concludes with a discussion of how clinics and health systems can tailor clinical services to the needs of LGBTQ youth.
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Affiliation(s)
- Scott E Hadland
- Division of Adolescent/Young Adult Medicine, Department of Medicine, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA; Department of Pediatrics, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA.
| | - Baligh R Yehia
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 1021 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104, USA; Penn Medicine Program for LGBT Health, Perelman School of Medicine, University of Pennsylvania, 1021 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104, USA
| | - Harvey J Makadon
- The Fenway Institute, Fenway Health, 1340 Boylston Street, Boston, MA 02215, USA; Department of Medicine, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
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12
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Berry SA, Fleishman JA, Yehia BR, Cheever LW, Hauck H, Korthuis PT, Mathews WC, Keruly J, Nijhawan AE, Agwu AL, Somboonwit C, Moore RD, Gebo KA. Healthcare Coverage for HIV Provider Visits Before and After Implementation of the Affordable Care Act. Clin Infect Dis 2016; 63:387-95. [PMID: 27143660 DOI: 10.1093/cid/ciw278] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2015] [Accepted: 02/17/2016] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Before implementation of the Patient Protection and Affordable Care Act (ACA) in 2014, 100 000 persons living with human immunodeficiency virus (HIV) (PLWH) lacked healthcare coverage and relied on a safety net of Ryan White HIV/AIDS Program support, local charities, or uncompensated care (RWHAP/Uncomp) to cover visits to HIV providers. We compared HIV provider coverage before (2011-2013) versus after (first half of 2014) ACA implementation among a total of 28 374 PLWH followed up in 4 sites in Medicaid expansion states (California, Oregon, and Maryland), 4 in a state (New York) that expanded Medicaid in 2001, and 2 in nonexpansion states (Texas and Florida). METHODS Multivariate multinomial logistic models were used to assess changes in RWHAP/Uncomp, Medicaid, and private insurance coverage, using Medicare as a referent. RESULTS In expansion state sites, RWHAP/Uncomp coverage decreased (unadjusted, 28% before and 13% after ACA; adjusted relative risk ratio [ARRR], 0.44; 95% confidence interval [CI], .40-.48). Medicaid coverage increased (23% and 38%; ARRR, 1.82; 95% CI, 1.70-1.94), and private coverage was unchanged (21% and 19%; 0.96; .89-1.03). In New York sites, both RWHAP/Uncomp (20% and 19%) and Medicaid (50% and 50%) coverage were unchanged, while private coverage decreased (13% and 12%; ARRR, 0.86; 95% CI, .80-.92). In nonexpansion state sites, RWHAP/Uncomp (57% and 52%) and Medicaid (18% and 18%) coverage were unchanged, while private coverage increased (4% and 7%; ARRR, 1.79; 95% CI, 1.62-1.99). CONCLUSIONS In expansion state sites, half of PLWH relying on RWHAP/Uncomp coverage shifted to Medicaid, while in New York and nonexpansion state sites, reliance on RWHAP/Uncomp remained constant. In the first half of 2014, the ACA did not eliminate the need for RWHAP safety net provider visit coverage.
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Affiliation(s)
- Stephen A Berry
- Department of Internal Medicine, Johns Hopkins University School of Medicine
| | - John A Fleishman
- Department of Center for Financing, Access and Cost Trends, Agency for Healthcare Research and Quality
| | - Baligh R Yehia
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Laura W Cheever
- Department of HIV/AIDS Bureau, Health Resources and Services Administration, Rockville, Maryland
| | - Heather Hauck
- Department of HIV/AIDS Bureau, Health Resources and Services Administration, Rockville, Maryland
| | - P Todd Korthuis
- Department of Medicine, Oregon Health & Science University, Portland
| | | | - Jeanne Keruly
- Department of Internal Medicine, Johns Hopkins University School of Medicine
| | - Ank E Nijhawan
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Allison L Agwu
- Department of Pediatrics, Johns Hopkins University, Baltimore
| | - Charurut Somboonwit
- Department of Internal Medicine, University of South Florida Morsani College of Medicine, Tampa
| | - Richard D Moore
- Department of Internal Medicine, Johns Hopkins University School of Medicine
| | - Kelly A Gebo
- Department of Internal Medicine, Johns Hopkins University School of Medicine
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Bonacci RA, Frasca K, Swift L, Sha D, Bilker WB, Bamford L, Yehia BR, Gross R. Antiretroviral Refill Adherence Correlates with, But Poorly Predicts Retention in HIV Care. AIDS Behav 2016; 20:1060-7. [PMID: 26400078 DOI: 10.1007/s10461-015-1205-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
If antiretroviral refill adherence could predict non-retention in care, it could be clinically useful. In a retrospective cohort study of HIV-infected adults in Philadelphia between October 2012 and April 2013, retention in care was measured by show versus no-show at an index visit. Three measures of adherence were defined per person: (1) percent of doses taken for two refills nearest index visit, (2) days late for last refill before index visit, and (3) longest gap between any two refills. Of 393 patients, 108 (27.4 %) no-showed. Adherence was higher in the show group on all measures with longest gap having the greatest difference: 40 days (IQR 33-56) in the show versus 47 days (IQR 38-69) in the no-show group, p < 0.001. Yet, no cut-points of adherence adequately predicted show versus no-show. Antiretroviral adherence being associated, but a poor predictor of retention suggests that these two behaviors are related but distinct phenomena.
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Lee L, Yehia BR, Gaur AH, Rutstein R, Gebo K, Keruly JC, Moore RD, Nijhawan AE, Agwu AL. The Impact of Youth-Friendly Structures of Care on Retention Among HIV-Infected Youth. AIDS Patient Care STDS 2016; 30:170-7. [PMID: 26983056 DOI: 10.1089/apc.2015.0263] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Limited data exist on how structures of care impact retention among youth living with HIV (YLHIV). We describe the availability of youth-friendly structures of care within HIV Research Network (HIVRN) clinics and examine their association with retention in HIV care. Data from 680 15- to 24-year-old YLHIV receiving care at 7 adult and 5 pediatric clinics in 2011 were included in the analysis. The primary outcome was retention in care, defined as completing ≥2 primary HIV care visits ≥90 days apart in a 12-month period. Sites were surveyed to assess the availability of clinic structures defined a priori as 'youth-friendly'. Univariate and multivariable logistic regression models assessed structures associated with retention in care. Among 680 YLHIV, 85% were retained. Nearly half (48%) of the 680 YLHIV attended clinics with youth-friendly waiting areas, 36% attended clinics with evening hours, 73% attended clinics with adolescent health-trained providers, 87% could email or text message providers, and 73% could schedule a routine appointment within 2 weeks. Adjusting for demographic and clinical factors, YLHIV were more likely to be retained in care at clinics with a youth-friendly waiting area (AOR 2.47, 95% CI [1.11-5.52]), evening clinic hours (AOR 1.94; 95% CI [1.13-3.33]), and providers with adolescent health training (AOR 1.98; 95% CI [1.01-3.86]). Youth-friendly structures of care impact retention in care among YLHIV. Further investigations are needed to determine how to effectively implement youth-friendly strategies across clinical settings where YLHIV receive care.
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Affiliation(s)
- Lana Lee
- Divisions of General Pediatrics and Adolescent Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Baligh R. Yehia
- Department of Infectious Diseases, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Aditya H. Gaur
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Richard Rutstein
- Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Kelly Gebo
- Divisions of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Jeanne C. Keruly
- Divisions of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Richard D. Moore
- Divisions of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Ank E. Nijhawan
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Allison L. Agwu
- Divisions of Adult and Pediatric Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
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Sánchez NF, Sánchez JP, Lunn MR, Yehia BR, Callahan EJ. First Annual LGBT Health Workforce Conference: Empowering Our Health Workforce to Better Serve LGBT Communities. LGBT Health 2016; 1:62-5. [PMID: 26789511 DOI: 10.1089/lgbt.2013.0020] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The Institute of Medicine has identified significant health disparities and barriers to health care experienced by lesbian, gay, bisexual, and transgender (LGBT) populations. By lowering financial barriers to care, recent legislation and judicial decisions have created a remarkable opportunity for reducing disparities by making health care available to those who previously lacked access. However, the current health-care workforce lacks sufficient training on LGBT-specific health-care issues and delivery of culturally competent care to sexual orientation and gender identity minorities. The LGBT Healthcare Workforce Conference was developed to provide a yearly forum to address these deficiencies through the sharing of best practices in LGBT health-care delivery, creating LGBT-inclusive institutional environments, supporting LGBT personal and professional development, and peer-to-peer mentoring, with an emphasis on students and early career professionals in the health-care fields. This report summarizes the findings of the first annual LGBT Health Workforce Conference.
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Affiliation(s)
- Nelson F Sánchez
- 1 Weill-Cornell Medical College and Memorial Sloan-Kettering Cancer Center , New York, New York
| | - John Paul Sánchez
- 2 Building the Next Generation of Academic Physicians Initiative, Hispanic Center of Excellence; Einstein LGBT Steering Committee, Albert Einstein College of Medicine; and Center for Lesbian and Gay Studies, City University of New York , New York, New York
| | - Mitchell R Lunn
- 3 Division of Nephrology, Department of Medicine, University of California-San Francisco , and Stanford LGBT Medical Education Research Group, Stanford University School of Medicine, San Francisco, California
| | - Baligh R Yehia
- 4 University of Pennsylvania Perelman School of Medicine and Penn Medicine Program for LGBT Health , Philadelphia, Pennsylvania
| | - Edward J Callahan
- 5 School of Medicine, University of California-Davis , Sacramento, California
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Farmer C, Yehia BR, Fleishman JA, Rutstein R, Mathews WC, Nijhawan A, Moore RD, Gebo KA, Agwu AL. Factors Associated With Retention Among Non-Perinatally HIV-Infected Youth in the HIV Research Network. J Pediatric Infect Dis Soc 2016; 5:39-46. [PMID: 26908490 PMCID: PMC4765490 DOI: 10.1093/jpids/piu102] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Accepted: 07/23/2014] [Indexed: 11/13/2022]
Abstract
BACKGROUND The transmission of human immunodeficiency virus (HIV) among youth through high-risk behaviors continues to increase. Retention in Care is associated with positive clinical outcomes and a decrease in HIV transmission risk behaviors. We evaluated the clinical and demographic characteristics of non-perinatally HIV (nPHIV)-infected youth associated with retention 1 year after initiating care and in the 2 years thereafter. We also assessed the impact retention in year 1 had on retention in years 2 and 3. METHODS This was a retrospective analysis of treatment-naive nPHIV-infected 12- to 24-year-old youth presenting for care in 16 US HIV clinical sites within the HIV Research Network between 2002 and 2008. Multivariate logistic regression identified factors associated with retention. RESULTS Of 1160 nPHIV-infected youth, 44.6% were retained in care during the first year, and 22.4% were retained in all 3 years. Retention in the first year was associated with starting antiretroviral therapy in the first year (adjusted odds ratio [AOR], 3.47 [95% confidence interval (CI), 2.57-4.67]), Hispanic ethnicity (AOR, 1.66 [95% CI, 1.08-2.56]), men who have sex with men (AOR, 1.59 [95% CI, 1.07-2.36]), and receiving care at a pediatric site (AOR, 5.37 [95% CI, 3.20-9.01]). Retention in years 2 and 3 was associated with being retained 1 year after initiating care (AOR, 7.44 [95% CI, 5.11-10.83]). CONCLUSION A high proportion of newly enrolled nPHIV-infected youth were not retained for 1 year, and only 1 in 4 were retained for 3 years. Patients who were Hispanic, were men who have sex with men, or were seen at pediatric clinics were more likely to be retained in care. Interventions that target those at risk of being lost to follow up are essential for this high-risk population.
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Affiliation(s)
| | - Baligh R. Yehia
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia
| | - John A. Fleishman
- Center for Financing, Access, and Cost Trends, Agency for Healthcare Research and Quality, Rockville, Maryland
| | - Richard Rutstein
- Division of General Pediatrics, Children's Hospital of Philadelphia, Pennsylvania
| | | | - Ank Nijhawan
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
| | - Richard D. Moore
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Kelly A. Gebo
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Allison L. Agwu
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland,Division of Pediatric Infectious Diseases, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
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17
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Rebeiro PF, Gange SJ, Horberg MA, Abraham AG, Napravnik S, Samji H, Yehia BR, Althoff KN, Moore RD, Kitahata MM, Sterling TR, Curriero FC. Geographic Variations in Retention in Care among HIV-Infected Adults in the United States. PLoS One 2016; 11:e0146119. [PMID: 26752637 PMCID: PMC4708981 DOI: 10.1371/journal.pone.0146119] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 12/14/2015] [Indexed: 11/18/2022] Open
Abstract
Objective To understand geographic variations in clinical retention, a central component of the HIV care continuum and key to improving individual- and population-level HIV outcomes. Design We evaluated retention by US region in a retrospective observational study. Methods Adults receiving care from 2000–2010 in 12 clinical cohorts of the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) contributed data. Individuals were assigned to Centers for Disease Control and Prevention (CDC)-defined regions by residential data (10 cohorts) and clinic location as proxy (2 cohorts). Retention was ≥2 primary HIV outpatient visits within a calendar year, >90 days apart. Trends and regional differences were analyzed using modified Poisson regression with clustering, adjusting for time in care, age, sex, race/ethnicity, and HIV risk, and stratified by baseline CD4+ count. Results Among 78,993 adults with 444,212 person-years of follow-up, median time in care was 7 years (Interquartile Range: 4–9). Retention increased from 2000 to 2010: from 73% (5,000/6,875) to 85% (7,189/8,462) in the Northeast, 75% (1,778/2,356) to 87% (1,630/1,880) in the Midwest, 68% (8,451/12,417) to 80% (9,892/12,304) in the South, and 68% (5,147/7,520) to 72% (6,401/8,895) in the West. In adjusted analyses, retention improved over time in all regions (p<0.01, trend), although the average percent retained lagged in the West and South vs. the Northeast (p<0.01). Conclusions In our population, retention improved, though regional differences persisted even after adjusting for demographic and HIV risk factors. These data demonstrate regional differences in the US which may affect patient care, despite national care recommendations.
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Affiliation(s)
- Peter F. Rebeiro
- Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- * E-mail:
| | - Stephen J. Gange
- Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Michael A. Horberg
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, Maryland, United States of America
| | - Alison G. Abraham
- Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Sonia Napravnik
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Hasina Samji
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Baligh R. Yehia
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, United States of America
| | - Keri N. Althoff
- Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Richard D. Moore
- Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Mari M. Kitahata
- University of Washington School of Medicine, Seattle, Washington, United States of America
| | - Timothy R. Sterling
- Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
| | - Frank C. Curriero
- Johns Hopkins University, Baltimore, Maryland, United States of America
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McClain Z, Hawkins LA, Yehia BR. Creating Welcoming Spaces for Lesbian, Gay, Bisexual, and Transgender (LGBT) Patients: An Evaluation of the Health Care Environment. J Homosex 2016; 63:387-93. [PMID: 26643126 DOI: 10.1080/00918369.2016.1124694] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Health outcomes are affected by patient, provider, and environmental factors. Previous studies have evaluated patient-level factors; few focusing on environment. Safe clinical spaces are important for lesbian, gay, bisexual, and transgender (LGBT) communities. This study evaluates current models of LGBT health care delivery, identifies strengths and weaknesses, and makes recommendations for LGBT spaces. Models are divided into LGBT-specific and LGBT-embedded care delivery. Advantages to both models exist, and they provide LGBT patients different options of healthcare. Yet certain commonalities must be met: a clean and confidential system. Once met, LGBT-competent environments and providers can advocate for appropriate care for LGBT communities, creating environments where they would want to seek care.
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Affiliation(s)
- Zachary McClain
- a Craig-Dalsimer Division of Adolescent Medicine , The Children's Hospital of Philadelphia , Philadelphia , Pennsylvania , USA
- b Penn Medicine Program for LGBT Health , University of Pennsylvania , Philadelphia , Pennsylvania , USA
| | - Linda A Hawkins
- a Craig-Dalsimer Division of Adolescent Medicine , The Children's Hospital of Philadelphia , Philadelphia , Pennsylvania , USA
- b Penn Medicine Program for LGBT Health , University of Pennsylvania , Philadelphia , Pennsylvania , USA
- c Social Work and Family Services Department , The Children's Hospital of Philadelphia , Philadelphia , Pennsylvania , USA
| | - Baligh R Yehia
- b Penn Medicine Program for LGBT Health , University of Pennsylvania , Philadelphia , Pennsylvania , USA
- d Department of Medicine , University of Pennsylvania Perelman School of Medicine , Philadelphia , Pennsylvania , USA
- e Leonard Davis Institute of Health Economics , University of Pennsylvania , Philadelphia , Pennsylvania , USA
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Rebeiro PF, Althoff KN, Lau B, Gill J, Abraham AG, Horberg MA, Kitahata MM, Yehia BR, Samji H, Brooks JT, Buchacz K, Napravnik S, Silverberg MJ, Rachlis A, Gebo KA, Sterling TR, Moore RD, Gange SJ. Laboratory Measures as Proxies for Primary Care Encounters: Implications for Quantifying Clinical Retention Among HIV-Infected Adults in North America. Am J Epidemiol 2015; 182:952-60. [PMID: 26578717 DOI: 10.1093/aje/kwv181] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2014] [Accepted: 06/29/2015] [Indexed: 11/13/2022] Open
Abstract
Because of limitations in the availability of data on primary care encounters, patient retention in human immunodeficiency virus (HIV) care is often estimated using laboratory measurement dates as proxies for clinical encounters, leading to possible outcome misclassification. This study included 83,041 HIV-infected adults from 14 clinical cohorts in the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) who had ≥1 HIV primary care encounters during 2000-2010, contributing 468,816 person-years of follow-up. Encounter-based retention (REB) was defined as ≥2 encounters in a calendar year, ≥90 days apart. Laboratory-based retention (RLB) was defined similarly, using the dates of CD4-positive cell counts or HIV-1 RNA measurements. Percentage of agreement and the κ statistic were used to characterize agreement between RLB and REB. Logistic regression with generalized estimating equations and stabilized inverse-probability-of-selection weights was used to elucidate temporal trends and the discriminatory power of RLB as a predictor of REB, accounting for age, sex, race/ethnicity, primary HIV risk factor, and cohort site as potential confounders. Both REB and RLB increased from 2000 to 2010 (from 67% to 78% and from 65% to 77%, respectively), though REB was higher than RLB throughout (P < 0.01). RLB agreed well with REB (80%-86% agreement; κ = 0.55-0.62, P < 0.01) and had a strong, imperfect ability to discriminate between persons retained and not retained in care by REB (C statistic: C = 0.81, P < 0.05). As a proxy for REB, RLB had a sensitivity and specificity of 84% and 77%, respectively, with misclassification error of 18%.
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20
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Berry SA, Ghanem KG, Mathews WC, Korthuis PT, Yehia BR, Agwu AL, Lehmann CU, Moore RD, Allen SL, Gebo KA. Brief Report: Gonorrhea and Chlamydia Testing Increasing but Still Lagging in HIV Clinics in the United States. J Acquir Immune Defic Syndr 2015; 70:275-9. [PMID: 26068721 PMCID: PMC4607588 DOI: 10.1097/qai.0000000000000711] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Screening persons living with HIV for gonorrhea and chlamydia has been recommended since 2003. We compared annual gonorrhea/chlamydia testing to syphilis and lipid testing among 19,368 adults (41% men who have sex with men, 30% heterosexual men, and 29% women) engaged in HIV care. In 2004, 22%, 62%, and 70% of all patients were tested for gonorrhea/chlamydia, syphilis, and lipid levels, respectively. Despite increasing steadily [odds ratio per year (95% confidence interval): 1.14 (1.13 to 1.15)], gonorrhea/chlamydia testing in 2010 remained lower than syphilis and lipid testing (39%, 77%, 76%, respectively). Interventions to improve gonorrhea/chlamydia screening are needed. A more targeted screening approach may be warranted.
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Affiliation(s)
| | | | | | | | - Baligh R. Yehia
- University of Pennsylvania School of Medicine, Philadelphia PA
| | | | | | | | - Sara L. Allen
- Drexel University School of Medicine, Philadelphia PA
| | - Kelly A. Gebo
- Johns Hopkins University School of Medicine, Baltimore MD
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Adams JW, Brady KA, Michael YL, Yehia BR, Momplaisir FM. Postpartum Engagement in HIV Care: An Important Predictor of Long-term Retention in Care and Viral Suppression. Clin Infect Dis 2015; 61:1880-7. [DOI: 10.1093/cid/civ678] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Accepted: 07/28/2015] [Indexed: 01/21/2023] Open
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Abstract
Improving outcomes for people with HIV and mental illness will be critical to meeting the goals of the US National HIV/AIDS Strategy. In a retrospective analysis of the 2008-2010 cycles of the locally representative Philadelphia Medical Monitoring Project, we compared the proportions of HIV-infected adults with and without mental illness: (1) retained in care (≥2 primary HIV visits separated by ≥90 days in a 12-month period); (2) prescribed antiretroviral therapy (ART) at any point in a 12-month period; and (3) virally suppressed (HIV-1 RNA ≤200 copies/mL at the last measure in the 12-month period). Multivariable regression assessed associations between mental illness and the outcomes, adjusting for age, gender, race/ethnicity, insurance, alcohol abuse, injection drug use, CD4 count, and calendar year. Of 730 HIV-infected persons, representative of 9409 persons in care for HIV in Philadelphia, 49.0 % had mental illness. In adjusted analyses, there were no significant differences in retention (91.3 vs. 90.3 %; AOR 1.30, 95 % CI 0.63-2.56) and prescription of ART (83.2 vs. 88.7 %; AOR 0.79, 95 % CI 0.49-1.25) between those with and without mental illness. However, mentally ill patients were less likely to achieve viral suppression than those without mental illness (65.9 vs. 74.4 %; AOR 0.64, 95 % CI 0.46-0.90). These findings argue for the need to optimize ART adherence in this population.
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Affiliation(s)
- Baligh R Yehia
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 1021 Blockley Hall, 423 Guardian Drive, Philadelphia, PA, 19104, USA,
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Abstract
Health behaviors such as retention in HIV medical care and adherence to antiretroviral therapy (ART) pose major challenges to reducing new HIV infections, addressing health disparities, and improving health outcomes. Andersen's Behavioral Model of Health Service Use provides a conceptual framework for understanding how patient and environmental factors affect health behaviors and outcomes, which can inform the design of intervention strategies. Factors affecting retention and adherence among persons with HIV include patient predisposing factors (e.g., mental illness, substance abuse), patient-enabling factors (e.g., social support, reminder strategies, medication characteristics, transportation, housing, insurance), and healthcare environment factors (e.g., pharmacy services, clinic experiences, provider characteristics). Evidence-based recommendations for improving retention and adherence include (1) systematic monitoring of clinic attendance and ART adherence; (2) use of peer or paraprofessional navigators to re-engage patients in care and help them remain in care; (3) optimization of ART regimens and pharmaceutical supply chain management systems; (4) provision of reminder devices and tools; (5) general education and counseling; (6) engagement of peer, family, and community support groups; (7) case management; and (8) targeting patients with substance abuse and mental illness. Further research is needed on effective monitoring strategies and interventions that focus on improving retention and adherence, with specific attention to the healthcare environment.
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Affiliation(s)
- Carol W Holtzman
- ICAP, Columbia University Mailman School of Public Health, P.O. Box 13860, Maseru 100, Lesotho,
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Yehia BR, Mody A, Stewart L, Holtzman CW, Jacobs LM, Hines J, Mounzer K, Glanz K, Metlay JP, Shea JA. Impact of the Outpatient Clinic Experience on Retention in Care: Perspectives of HIV-Infected Patients and Their Providers. AIDS Patient Care STDS 2015; 29:365-9. [PMID: 26061902 DOI: 10.1089/apc.2015.0049] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Baligh R. Yehia
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Aaloke Mody
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Leslie Stewart
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Carol W. Holtzman
- ICAP, Columbia University Mailman School of Public Health, Maseru, Lesotho
| | - Lisa M. Jacobs
- Department of Family Medicine and Community Health, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Janet Hines
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Karam Mounzer
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- The Jonathan Lax Center, Philadelphia FIGHT, Philadelphia, Pennsylvania
| | - Karen Glanz
- Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Biobehavioral Health Sciences, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | - Joshua P. Metlay
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Judy A. Shea
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Momplaisir FM, Brady KA, Fekete T, Thompson DR, Diez Roux A, Yehia BR. Time of HIV Diagnosis and Engagement in Prenatal Care Impact Virologic Outcomes of Pregnant Women with HIV. PLoS One 2015; 10:e0132262. [PMID: 26132142 PMCID: PMC4489492 DOI: 10.1371/journal.pone.0132262] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Accepted: 06/11/2015] [Indexed: 11/23/2022] Open
Abstract
Background HIV suppression at parturition is beneficial for maternal, fetal and public health. To eliminate mother-to-child transmission of HIV, an understanding of missed opportunities for antiretroviral therapy (ART) use during pregnancy and HIV suppression at delivery is required. Methodology We performed a retrospective analysis of 836 mother-to-child pairs involving 656 HIV-infected women in Philadelphia, 2005-2013. Multivariable regression examined associations between patient (age, race/ethnicity, insurance status, drug use) and clinical factors such as adequacy of prenatal care measured by the Kessner index which classifies prenatal care as inadequate, intermediate, or adequate prenatal care; timing of HIV diagnosis; and the outcomes: receipt of ART during pregnancy and viral suppression at delivery. Results Overall, 25% of the sample was diagnosed with HIV during pregnancy; 39%, 38%, and 23% were adequately, intermediately, and inadequately engaged in prenatal care. Eight-five percent of mother-to-child pairs received ART during pregnancy but only 52% achieved suppression at delivery. Adjusting for patient factors, pairs diagnosed with HIV during pregnancy were less likely to receive ART (AOR 0.39, 95% CI 0.25-0.61) and achieve viral suppression (AOR 0.70, 95% CI 0.49-1.00) than those diagnosed before pregnancy. Similarly, women with inadequate prenatal care were less likely to receive ART (AOR 0.06, 95% CI 0.03-0.11) and achieve viral suppression (AOR 0.31, 95% CI 0.20-0.47) than those with adequate prenatal care. Conclusions Targeted interventions to diagnose HIV prior to pregnancy and engage HIV-infected women in prenatal care have the potential to improve HIV related outcomes in the perinatal period.
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Affiliation(s)
- Florence M. Momplaisir
- Division of Infectious Diseases and HIV Medicine, Drexel University School of Medicine, Philadelphia, Pennsylvania, United States of America
- * E-mail:
| | - Kathleen A. Brady
- AIDS Activities and Coordinating Office, Philadelphia Department of Public Health, Philadelphia, Pennsylvania, United States of America
- Division of Infectious Diseases, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Thomas Fekete
- Division of Infectious Diseases, Temple University Hospital, Philadelphia, Pennsylvania, United States of America
| | - Dana R. Thompson
- Center for Women’s and Children’s Health Research, Christiana Care Health System, Greenville, Delaware, United States of America
| | - Ana Diez Roux
- Drexel University School of Public Health, Philadelphia, Pennsylvania, United States of America
| | - Baligh R. Yehia
- Division of Infectious Diseases, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
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Yehia BR, Stewart L, Momplaisir F, Mody A, Holtzman CW, Jacobs LM, Hines J, Mounzer K, Glanz K, Metlay JP, Shea JA. Barriers and facilitators to patient retention in HIV care. BMC Infect Dis 2015; 15:246. [PMID: 26123158 PMCID: PMC4485864 DOI: 10.1186/s12879-015-0990-0] [Citation(s) in RCA: 154] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2014] [Accepted: 06/18/2015] [Indexed: 12/04/2022] Open
Abstract
Background Retention in HIV care improves survival and reduces the risk of HIV transmission to others. Multiple quantitative studies have described demographic and clinical characteristics associated with retention in HIV care. However, qualitative studies are needed to better understand barriers and facilitators. Methods Semi-structured interviews were conducted with 51 HIV-infected individuals, 25 who were retained in care and 26 not retained in care, from 3 urban clinics. Interview data were analyzed for themes using a modified grounded theory approach. Identified themes were compared between the two groups of interest: patients retained in care and those not retained in care. Results Overall, participants identified 12 barriers and 5 facilitators to retention in HIV care. On average, retained individuals provided 3 barriers, while persons not retained in care provided 5 barriers. Both groups commonly discussed depression/mental illness, feeling sick, and competing life activities as barriers. In addition, individuals not retained in care commonly reported expensive and unreliable transportation, stigma, and insufficient insurance as barriers. On average, participants in both groups referenced 2 facilitators, including the presence of social support, patient-friendly clinic services (transportation, co-location of services, scheduling/reminders), and positive relationships with providers and clinic staff. Conclusions In our study, patients not retained in care faced more barriers, particularly social and structural barriers, than those retained in care. Developing care models where social and financial barriers are addressed, mental health and substance abuse treatment is integrated, and patient-friendly services are offered is important to keeping HIV-infected individuals engaged in care.
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Affiliation(s)
- Baligh R Yehia
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA. .,University of Pennsylvania Perelman School of Medicine, 1021 Blockley Hall, 423 Guardian Drive, Philadelphia, PA, 19104, USA.
| | - Leslie Stewart
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Florence Momplaisir
- Department of Medicine, Drexel University School of Medicine, Philadelphia, PA, USA.
| | - Aaloke Mody
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Carol W Holtzman
- Department of Pharmacy Practice, Temple University School of Pharmacy, Philadelphia, PA, USA.
| | - Lisa M Jacobs
- Department of Family Medicine and Community Health, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Janet Hines
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Karam Mounzer
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA. .,The Jonathan Lax Center, Philadelphia FIGHT, Philadelphia, PA, USA.
| | - Karen Glanz
- Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA. .,Department of Biobehavioral Health Sciences, University of Pennsylvania School of Nursing, Philadelphia, PA, USA.
| | - Joshua P Metlay
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA.
| | - Judy A Shea
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
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Yehia BR, Stephens-Shields AJ, Fleishman JA, Berry SA, Agwu AL, Metlay JP, Moore RD, Christopher Mathews W, Nijhawan A, Rutstein R, Gaur AH, Gebo KA. The HIV Care Continuum: Changes over Time in Retention in Care and Viral Suppression. PLoS One 2015; 10:e0129376. [PMID: 26086089 PMCID: PMC4473034 DOI: 10.1371/journal.pone.0129376] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 05/07/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The HIV care continuum (diagnosis, linkage to care, retention in care, receipt of antiretroviral therapy (ART), viral suppression) has been used to identify opportunities for improving the delivery of HIV care. Continuum steps are typically calculated in a conditional manner, with the number of persons completing the prior step serving as the base population for the next step. This approach may underestimate the prevalence of viral suppression by excluding patients who are suppressed but do not meet standard definitions of retention in care. Understanding how retention in care and viral suppression interact and change over time may improve our ability to intervene on these steps in the continuum. METHODS We followed 17,140 patients at 11 U.S. HIV clinics between 2010-2012. For each calendar year, patients were classified into one of five categories: (1) retained/suppressed, (2) retained/not-suppressed, (3) not-retained/suppressed, (4) not-retained/not-suppressed, and (5) lost to follow-up (for calendar years 2011 and 2012 only). Retained individuals were those completing ≥ 2 HIV medical visits separated by ≥ 90 days in the year. Persons not retained completed ≥ 1 HIV medical visit during the year, but did not meet the retention definition. Persons lost to follow-up had no HIV medical visits in the year. HIV viral suppression was defined as HIV-1 RNA ≤ 200 copies/mL at the last measure in the year. Multinomial logistic regression was used to determine the probability of patients' transitioning between retention/suppression categories from 2010 to 2011 and 2010 to 2012, adjusting for age, sex, race/ethnicity, HIV risk factor, insurance status, CD4 count, and use of ART. RESULTS Overall, 65.8% of patients were retained/suppressed, 17.4% retained/not-suppressed, 10.0% not-retained/suppressed, and 6.8% not-retained/not-suppressed in 2010. 59.5% of patients maintained the same status in 2011 (kappa=0.458) and 53.3% maintained the same status in 2012 (kappa=0.437). CONCLUSIONS Not counting patients not-retained/suppressed as virally suppressed, as is commonly done in the HIV care continuum, underestimated the proportion suppressed by 13%. Applying the care continuum in a longitudinal manner will enhance its utility.
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Affiliation(s)
- Baligh R. Yehia
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States of America
- Center for Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
- * E-mail:
| | - Alisa J. Stephens-Shields
- Center for Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - John A. Fleishman
- Center for Financing, Access, and Cost Trends, Agency for Healthcare Research and Quality, Rockville, MD, United States of America
| | - Stephen A. Berry
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Allison L. Agwu
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Joshua P. Metlay
- General Medicine Division, Massachusetts General Hospital, Boston, MA, United States of America
| | - Richard D. Moore
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - W. Christopher Mathews
- Department of Medicine, University of California San Diego, San Diego, CA, United States of America
| | - Ank Nijhawan
- Department of Medicine, University of Texas Southwestern, Dallas, TX, United States of America
| | - Richard Rutstein
- Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, United States of America
| | - Aditya H. Gaur
- Department of Infectious Diseases, St. Jude’s Children's Hospital, Memphis, TN, United States of America
| | - Kelly A. Gebo
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
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Suneja G, Boyer M, Yehia BR, Shiels MS, Engels EA, Bekelman JE, Long JA. Cancer Treatment in Patients With HIV Infection and Non-AIDS-Defining Cancers: A Survey of US Oncologists. J Oncol Pract 2015; 11:e380-7. [PMID: 25873060 DOI: 10.1200/jop.2014.002709] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
PURPOSE HIV-infected individuals with non-AIDS-defining cancers are less likely to receive cancer treatment compared with uninfected individuals. We sought to identify provider-level factors influencing the delivery of oncology care to HIV-infected patients. METHODS A survey was mailed to 500 randomly selected US medical and radiation oncologists. The primary outcome was delivery of standard treatment, assessed by responses to three specialty-specific management questions. We used the χ(2) test to evaluate associations between delivery of standard treatment, provider demographics, and perceptions of HIV-infected individuals. Multivariable logistic regression identified associations using factor analysis to combine several correlated survey questions. RESULTS Our response rate was 60%; 69% of respondents felt that available cancer management guidelines were insufficient for the care of HIV-infected patients with cancer; 45% never or rarely discussed their cancer management plan with an HIV specialist; 20% and 15% of providers were not comfortable discussing cancer treatment adverse effects and prognosis with their HIV-infected patients with cancer, respectively; 79% indicated that they would provide standard cancer treatment to HIV-infected patients. In multivariable analysis, physicians comfortable discussing adverse effects and prognosis were more likely to provide standard cancer treatment (adjusted odds ratio, 1.52; 95% CI, 1.12 to 2.07). Physicians with concerns about toxicity and efficacy of treatment were significantly less likely to provide standard cancer treatment (adjusted odds ratio, 0.67; 95% CI, 0.53 to 0.85). CONCLUSION Provider-level factors are associated with delivery of nonstandard cancer treatment to HIV-infected patients. Policy change, provider education, and multidisciplinary collaboration are needed to improve access to cancer treatment.
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Affiliation(s)
- Gita Suneja
- University of Utah, Salt Lake City, UT; Marshall University, Huntington, WV; University of Pennsylvania; Veterans Affairs Center for Health Equity Research and Promotion, Philadelphia, PA; and National Cancer Institute, Bethesda, MD
| | - Matthew Boyer
- University of Utah, Salt Lake City, UT; Marshall University, Huntington, WV; University of Pennsylvania; Veterans Affairs Center for Health Equity Research and Promotion, Philadelphia, PA; and National Cancer Institute, Bethesda, MD
| | - Baligh R Yehia
- University of Utah, Salt Lake City, UT; Marshall University, Huntington, WV; University of Pennsylvania; Veterans Affairs Center for Health Equity Research and Promotion, Philadelphia, PA; and National Cancer Institute, Bethesda, MD
| | - Meredith S Shiels
- University of Utah, Salt Lake City, UT; Marshall University, Huntington, WV; University of Pennsylvania; Veterans Affairs Center for Health Equity Research and Promotion, Philadelphia, PA; and National Cancer Institute, Bethesda, MD
| | - Eric A Engels
- University of Utah, Salt Lake City, UT; Marshall University, Huntington, WV; University of Pennsylvania; Veterans Affairs Center for Health Equity Research and Promotion, Philadelphia, PA; and National Cancer Institute, Bethesda, MD
| | - Justin E Bekelman
- University of Utah, Salt Lake City, UT; Marshall University, Huntington, WV; University of Pennsylvania; Veterans Affairs Center for Health Equity Research and Promotion, Philadelphia, PA; and National Cancer Institute, Bethesda, MD
| | - Judith A Long
- University of Utah, Salt Lake City, UT; Marshall University, Huntington, WV; University of Pennsylvania; Veterans Affairs Center for Health Equity Research and Promotion, Philadelphia, PA; and National Cancer Institute, Bethesda, MD
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Agwu AL, Lee L, Fleishman JA, Voss C, Yehia BR, Althoff KN, Rutstein R, Mathews WC, Nijhawan A, Moore RD, Gaur AH, Gebo KA. Aging and loss to follow-up among youth living with human immunodeficiency virus in the HIV Research Network. J Adolesc Health 2015; 56:345-51. [PMID: 25703322 PMCID: PMC4378241 DOI: 10.1016/j.jadohealth.2014.11.009] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Revised: 10/17/2014] [Accepted: 11/14/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE In the United States, 21 years is a critical age of legal and social transition, with changes in social programs such as public insurance coverage. Human immunodeficiency virus (HIV)-infected youth have lower adherence to care and medications and may be at risk of loss to follow-up (LTFU) at this benchmark age. We evaluated LTFU after the 22nd birthday for HIV-infected youth engaged in care. LTFU was defined as having no primary HIV visits in the year after the 22nd birthday. METHODS All HIV-infected 21-year-olds engaged in care (2002-2011) at the HIV Research Network clinics were included. We assessed the proportion LTFU and used multivariable logistic regression to evaluate demographic and clinical characteristics associated with LTFU after the 22nd birthday. We compared LTFU at other age transitions during the adolescent/young adult years. RESULTS Six hundred forty-seven 21-year-olds were engaged in care; 91 (19.8%) were LTFU in the year after turning 22 years. Receiving care at an adult versus pediatric HIV clinic (adjusted odds ratio [AOR], 2.91; 95% confidence interval [CI], 1.42-5.93), having fewer than four primary HIV visits/year (AOR, 2.72; 95% CI, 1.67-4.42), and antiretroviral therapy prescription (AOR, .50; 95% CI, .41-.60) were independently associated with LTFU. LTFU was prevalent at each age transition, with factors associated with LTFU similar to that identified for 21-year-olds. CONCLUSIONS Although 19.8% of 21-year-olds at the HIV Research Network sites were LTFU after their 22nd birthday, significant proportions of youth of all ages were LTFU. Fewer than four primary HIV care visits/year, receiving care at adult clinics and not prescribed antiretroviral therapy, were associated with LTFU and may inform targeted interventions to reduce LTFU for these vulnerable patients.
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Affiliation(s)
- Allison L. Agwu
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland,Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland,Address correspondence to: Allison L. Agwu, M.D., Sc.M., Division of Pediatric Infectious Diseases, Department of Pediatrics, Johns Hopkins Medical Institutions, 200 N. Wolfe Street, Room 3145, Baltimore, MD 21287. (A.L. Agwu)
| | - Lana Lee
- Division of General Pediatrics and Adolescent Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - John A. Fleishman
- Center for Financing, Access, and Cost Trends, Agency for Healthcare Research and Quality, Rockville, Maryland
| | - Cindy Voss
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Baligh R. Yehia
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Keri N. Althoff
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Richard Rutstein
- Division of General Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - W. Christopher Mathews
- Department of Clinical Medicine, University of California San Diego Medical Center, San Diego, California
| | - Ank Nijhawan
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas Texas
| | - Richard D. Moore
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Aditya H. Gaur
- Department of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Kelly A. Gebo
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
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Schranz AJ, Brady KA, Momplaisir F, Metlay JP, Stephens A, Yehia BR. Comparison of HIV outcomes for patients linked at hospital versus community-based clinics. AIDS Patient Care STDS 2015; 29:117-25. [PMID: 25665013 DOI: 10.1089/apc.2014.0199] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Outpatient care for people living with HIV is delivered in diverse settings. Differences in setting may impact HIV outcomes. We evaluated HIV-infected adults in care at Ryan White-funded clinics in Philadelphia, PA, between 2008 and 2011 to determine how setting of care (hospital versus community-based) influenced HIV outcomes. Clinics were categorized as hospital-based if they were located onsite at a hospital. The composite outcome was completion of the final three steps of the HIV care continuum: (1) retention in care; (2) use of antiretroviral therapy (ART); and (3) viral suppression. Mixed-effects logistic regression, accounting for patient and clinic factors, examined the relationship between care setting and the outcome. In total, 12,637 patients, contributing 32,515 patient-years, received care at 25 clinics (12 hospital-based). Women, non-Hispanic blacks, those with private insurance, and individuals with higher household incomes more commonly attended hospital-based clinics (p<0.05). Of the 12,962 patient-years (40%) during which patients attended community-based clinics, 59% met the outcome. Similarly, 59% of the 19,553 patient-years (60%) in which patients attended hospital-based clinics met the outcome. Adjusting for patient and clinic factors, setting was not associated with the outcome (adjusted odds ratio=1.24, 95% CI=0.84-1.84). In summary, demographics differ among patients visiting hospital and community-based clinics. Completion of the final three steps of the HIV care continuum did not vary between hospital and community-based clinics, which may reflect advances in HIV therapy and the wide availability of HIV care resources.
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Affiliation(s)
- Asher J. Schranz
- Department of Medicine, New York University School of Medicine, New York, New York
| | - Kathleen A. Brady
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- AIDS Activities Coordinating Office, Philadelphia Department of Public Health, Philadelphia, Pennsylvania
| | - Florence Momplaisir
- Department of Medicine, Drexel University School of Medicine, Philadelphia, Pennsylvania
| | - Joshua P. Metlay
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Alisa Stephens
- Center for Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Baligh R. Yehia
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Center for Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
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Holtzman CW, Shea JA, Glanz K, Jacobs LM, Gross R, Hines J, Mounzer K, Samuel R, Metlay JP, Yehia BR. Mapping patient-identified barriers and facilitators to retention in HIV care and antiretroviral therapy adherence to Andersen's Behavioral Model. AIDS Care 2015; 27:817-28. [PMID: 25671515 DOI: 10.1080/09540121.2015.1009362] [Citation(s) in RCA: 104] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Andersen's Behavioral Model (ABM) provides a framework for understanding how patient and environmental factors impact health behaviors and outcomes. We compared patient-identified barriers/facilitators to retention in care and antiretroviral therapy (ART) adherence and evaluated how they mapped to ABM. Qualitative semi-structured interviews with 51 HIV-infected adults at HIV clinics in Philadelphia, PA, in 2013 were used to explore patients' experiences with HIV care and treatment. Interview data were analyzed for themes using a grounded theory approach. Among those interviewed, 53% were male and 88% were nonwhite; 49% were retained in care, 96% were on ART, and 57% were virally suppressed. Patients discussed 18 barriers/facilitators to retention in care and ART adherence: 11 common to both behaviors (stigma, mental illness, substance abuse, social support, reminder strategies, housing, insurance, symptoms, competing life activities, colocation of services, provider factors), 3 distinct to retention (transportation, clinic experiences, appointment scheduling), and 4 distinct to adherence (medication characteristics, pharmacy services, health literacy, health beliefs). Identified barriers/facilitators mapped to all ABM domains. These data support the use of ABM as a framework for classifying factors influencing HIV-specific health behaviors and have the potential to inform the design of interventions to improve retention in care and ART adherence.
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Affiliation(s)
- Carol W Holtzman
- a Department of Pharmacy Practice , Temple University School of Pharmacy , Philadelphia , PA , USA
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Yehia BR, Calder D, Flesch JD, Hirsh RL, Higginbotham E, Tkacs N, Crawford B, Fishman N. Advancing LGBT Health at an Academic Medical Center: A Case Study. LGBT Health 2014; 2:362-6. [PMID: 26788778 DOI: 10.1089/lgbt.2014.0054] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Academic health centers are strategically positioned to impact the health of lesbian, gay, bisexual and transgender (LGBT) populations by advancing science, educating future generations of providers, and delivering integrated care that addresses the unique health needs of the LGBT community. This report describes the early experiences of the Penn Medicine Program for LGBT Health, highlighting the favorable environment that led to its creation, the mission and structure of the Program, strategic planning process used to set priorities and establish collaborations, and the reception and early successes of the Program.
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Affiliation(s)
- Baligh R Yehia
- 1 Department of Medicine, University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania.,2 Leonard Davis Institute of Health Economics, University of Pennsylvania , Philadelphia, Pennsylvania.,3 Penn Medicine Program for LGBT Health, University of Pennsylvania , Philadelphia, Pennsylvania
| | - Daniel Calder
- 1 Department of Medicine, University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania.,3 Penn Medicine Program for LGBT Health, University of Pennsylvania , Philadelphia, Pennsylvania
| | - Judd D Flesch
- 1 Department of Medicine, University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania.,3 Penn Medicine Program for LGBT Health, University of Pennsylvania , Philadelphia, Pennsylvania
| | - Rebecca L Hirsh
- 1 Department of Medicine, University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania.,3 Penn Medicine Program for LGBT Health, University of Pennsylvania , Philadelphia, Pennsylvania
| | - Eve Higginbotham
- 2 Leonard Davis Institute of Health Economics, University of Pennsylvania , Philadelphia, Pennsylvania.,4 Office of Inclusion and Diversity, University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania
| | - Nancy Tkacs
- 5 Office of Diversity and Cultural Affairs, University of Pennsylvania School of Nursing , Philadelphia, Pennsylvania
| | - Beverley Crawford
- 6 Office of Diversity Affairs, University of Pennsylvania School of Dental Medicine , Philadelphia, Pennsylvania
| | - Neil Fishman
- 1 Department of Medicine, University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania.,3 Penn Medicine Program for LGBT Health, University of Pennsylvania , Philadelphia, Pennsylvania
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Crowell TA, Gebo KA, Blankson JN, Korthuis PT, Yehia BR, Rutstein RM, Moore RD, Sharp V, Nijhawan AE, Mathews WC, Hanau LH, Corales RB, Beil R, Somboonwit C, Edelstein H, Allen SL, Berry SA. Hospitalization Rates and Reasons Among HIV Elite Controllers and Persons With Medically Controlled HIV Infection. J Infect Dis 2014; 211:1692-702. [PMID: 25512624 DOI: 10.1093/infdis/jiu809] [Citation(s) in RCA: 90] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Accepted: 10/22/2014] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Elite controllers spontaneously suppress human immunodeficiency virus (HIV) viremia but also demonstrate chronic inflammation that may increase risk of comorbid conditions. We compared hospitalization rates and causes among elite controllers to those of immunologically intact persons with medically controlled HIV. METHODS For adults in care at 11 sites from 2005 to 2011, person-years with CD4 T-cell counts ≥350 cells/mm(2) were categorized as medical control, elite control, low viremia, or high viremia. All-cause and diagnostic category-specific hospitalization rates were compared between groups using negative binomial regression. RESULTS We identified 149 elite controllers (0.4%) among 34 354 persons in care. Unadjusted hospitalization rates among the medical control, elite control, low-viremia, and high-viremia groups were 10.5, 23.3, 12.6, and 16.9 per 100 person-years, respectively. After adjustment for demographic and clinical factors, elite control was associated with higher rates of all-cause (adjusted incidence rate ratio, 1.77 [95% confidence interval, 1.21-2.60]), cardiovascular (3.19 [1.50-6.79]) and psychiatric (3.98 [1.54-10.28]) hospitalization than was medical control. Non-AIDS-defining infections were the most common reason for admission overall (24.1% of hospitalizations) but were rare among elite controllers (2.7%), in whom cardiovascular hospitalizations were most common (31.1%). CONCLUSIONS Elite controllers are hospitalized more frequently than persons with medically controlled HIV and cardiovascular hospitalizations are an important contributor.
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Affiliation(s)
- Trevor A Crowell
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kelly A Gebo
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Joel N Blankson
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - P Todd Korthuis
- Department of Public Health/Preventive Medicine, Oregon Health and Science University, Portland
| | - Baligh R Yehia
- Department of Medicine, University of Pennsylvania Perelman School of Medicine
| | | | - Richard D Moore
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Victoria Sharp
- Center for Comprehensive Care, St Luke's Roosevelt Hospital Center
| | - Ank E Nijhawan
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
| | | | | | | | | | | | - Howard Edelstein
- Department of Internal Medicine, Alameda County Medical Center, Oakland, California
| | - Sara L Allen
- Department of Medicine, Drexel University College of Medicine, Pennsylvania
| | - Stephen A Berry
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Yehia BR, Cui W, Thompson WW, Zack MM, McKnight-Eily L, DiNenno E, Rose CE, Blank MB. HIV testing among adults with mental illness in the United States. AIDS Patient Care STDS 2014; 28:628-34. [PMID: 25459230 PMCID: PMC4250950 DOI: 10.1089/apc.2014.0196] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Nationally representative data from the 2007 National Health Interview Survey (NHIS) were used to compare HIV testing prevalence among US adults with mental illness (schizophrenia spectrum disorder, bipolar disorder, depression, and/or anxiety) to those without, providing an update of prior work using 1999 and 2002 NHIS data. Logistic regression modeling was used to estimate the probability of ever being tested for HIV by mental illness status, adjusting for age, sex, race/ethnicity, marital status, substance abuse, excessive alcohol or tobacco use, and HIV risk factors. Based on data from 21,785 respondents, 15% of adults had a psychiatric disorder and 37% ever had an HIV test. Persons with schizophrenia (64%), bipolar disorder (63%), and depression and/or anxiety (47%) were more likely to report ever being tested for HIV than those without mental illness (35%). In multivariable models, individuals reporting schizophrenia (adjusted prevalence ratio=1.68, 95% confidence interval=1.33-2.13), bipolar disease (1.58, 1.39-1.81), and depression and/or anxiety (1.31, 1.25-1.38) were more likely to be tested for HIV than persons without these diagnoses. Similar to previous analyses, persons with mental illness were more likely to have been tested than those without mental illness. However, the elevated prevalence of HIV in populations with mental illness suggests that high levels of testing along with other prevention efforts are needed.
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Affiliation(s)
- Baligh R. Yehia
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Wanjun Cui
- National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - William W. Thompson
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Matthew M. Zack
- National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Lela McKnight-Eily
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Elizabeth DiNenno
- National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Charles E. Rose
- National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Michael B. Blank
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Rebeiro PF, Horberg MA, Gange SJ, Gebo KA, Yehia BR, Brooks JT, Buchacz K, Silverberg MJ, Gill J, Moore RD, Althoff KN. Strong agreement of nationally recommended retention measures from the Institute of Medicine and Department of Health and Human Services. PLoS One 2014; 9:e111772. [PMID: 25375099 PMCID: PMC4222946 DOI: 10.1371/journal.pone.0111772] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Accepted: 10/02/2014] [Indexed: 11/22/2022] Open
Abstract
Objective We sought to quantify agreement between Institute of Medicine (IOM) and Department of Health and Human Services (DHHS) retention indicators, which have not been compared in the same population, and assess clinical retention within the largest HIV cohort collaboration in the U.S. Design Observational study from 2008–2010, using clinical cohort data in the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD). Methods Retention definitions used HIV primary care visits. The IOM retention indicator was: ≥2 visits, ≥90 days apart, each calendar year. This was extended to a 2-year period; retention required meeting the definition in both years. The DHHS retention indicator was: ≥1 visit each semester over 2 years, each ≥60 days apart. Kappa statistics detected agreement between indicators and C statistics (areas under Receiver-Operating Characteristic curves) from logistic regression analyses summarized discrimination of the IOM indicator by the DHHS indicator. Results Among 36,769 patients in 2008–2009 and 34,017 in 2009–2010, there were higher percentages of participants retained in care under the IOM indicator than the DHHS indicator (80% vs. 75% in 2008–2009; 78% vs. 72% in 2009–2010, respectively) (p<0.01), persisting across all demographic and clinical characteristics (p<0.01). There was high agreement between indicators overall (κ = 0.83 in 2008–2009; κ = 0.79 in 2009–2010, p<0.001), and C statistics revealed a very strong ability to predict retention according to the IOM indicator based on DHHS indicator status, even within characteristic strata. Conclusions Although the IOM indicator consistently reported higher retention in care compared with the DHHS indicator, there was strong agreement between IOM and DHHS retention indicators in a cohort demographically similar to persons living with HIV/AIDS in the U.S. Persons with poorer retention represent subgroups of interest for retention improvement programs nationally, particularly in light of the White House Executive Order on the HIV Care Continuum.
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Affiliation(s)
- Peter F. Rebeiro
- Johns Hopkins University, Baltimore, MD, United States of America
- * E-mail: (PFR); (KNA)
| | - Michael A. Horberg
- Kaiser Permanente Mid-Atlantic States, Rockville, MD, United States of America
| | - Stephen J. Gange
- Johns Hopkins University, Baltimore, MD, United States of America
| | - Kelly A. Gebo
- Johns Hopkins University, Baltimore, MD, United States of America
| | - Baligh R. Yehia
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States of America
| | - John T. Brooks
- Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Kate Buchacz
- Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | | | - John Gill
- University of Calgary, Calgary, AB, Canada
| | - Richard D. Moore
- Johns Hopkins University, Baltimore, MD, United States of America
| | - Keri N. Althoff
- Johns Hopkins University, Baltimore, MD, United States of America
- * E-mail: (PFR); (KNA)
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Nguyen GT, Yehia BR. Documentation of sexual partner gender is low in electronic health records: observations, predictors, and recommendations to improve population health management in primary care. Popul Health Manag 2014; 18:217-22. [PMID: 25290634 DOI: 10.1089/pop.2014.0075] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The 2011 Institute of Medicine report on LGBT health recommended that sexual orientation and gender identity (SO/GI) be documented in electronic health records (EHRs). Most EHRs cannot document all aspects of SO/GI, but some can record gender of sexual partners. This study sought to determine the proportion of patients who have the gender of sexual partners recorded in the EHR and to identify factors associated with documentation. A retrospective analysis was done of EHR data for 40 family medicine (FM) and general internal medicine (IM) practices, comprising 170,570 adult patients seen in 2012. The primary outcome was EHR documentation of sexual partner gender. Multivariate logistic regression assessed the impact of patient, provider, and practice factors on documentation. In all, 76,767 patients (45%) had the gender of sexual partners recorded, 4.3% of whom had same-gender partners (3.5% of females, 5.6% of males). Likelihood of documentation was independently higher for women; blacks; those with a preventive visit; those with a physician assistant, nurse practitioner, or resident primary care provider (vs. attending); those at urban practices; those at smaller practices; and those at a residency FM practice. Older age and Medicare insurance were associated with lower documentation. Sexual partner gender documentation is important to identify patients for targeted prevention and support, and holds great potential for population health management, yet documentation in the EHR currently is low. Primary care practices should routinely record the gender of sexual partners, and additional work is needed to identify best practices for collecting and using SO/GI data in this setting.
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Affiliation(s)
- Giang T Nguyen
- 1Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,2Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania.,3Center for Public Health Initiatives, University of Pennsylvania, Philadelphia, Pennsylvania.,4Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania.,5Penn Medicine Program for LGBT Health, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Baligh R Yehia
- 2Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania.,3Center for Public Health Initiatives, University of Pennsylvania, Philadelphia, Pennsylvania.,4Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania.,5Penn Medicine Program for LGBT Health, University of Pennsylvania, Philadelphia, Pennsylvania.,6Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Yehia BR, Herati RS, Fleishman JA, Gallant JE, Agwu AL, Berry SA, Korthuis PT, Moore RD, Metlay JP, Gebo KA. Hepatitis C virus testing in adults living with HIV: a need for improved screening efforts. PLoS One 2014; 9:e102766. [PMID: 25032989 PMCID: PMC4102540 DOI: 10.1371/journal.pone.0102766] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Accepted: 06/21/2014] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES Guidelines recommend hepatitis C virus (HCV) screening for all people living with HIV (PLWH). Understanding HCV testing practices may improve compliance with guidelines and can help identify areas for future intervention. METHODS We evaluated HCV screening and unnecessary repeat HCV testing in 8,590 PLWH initiating care at 12 U.S. HIV clinics between 2006 and 2010, with follow-up through 2011. Multivariable logistic regression examined the association between patient factors and the outcomes: HCV screening (≥1 HCV antibody tests during the study period) and unnecessary repeat HCV testing (≥1 HCV antibody tests in patients with a prior positive test result). RESULTS Overall, 82% of patients were screened for HCV, 18% of those screened were HCV antibody-positive, and 40% of HCV antibody-positive patients had unnecessary repeat HCV testing. The likelihood of being screened for HCV increased as the number of outpatient visits rose (adjusted odds ratio 1.02, 95% confidence interval 1.01-1.03). Compared to men who have sex with men (MSM), patients with injection drug use (IDU) were less likely to be screened for HCV (0.63, 0.52-0.78); while individuals with Medicaid were more likely to be screened than those with private insurance (1.30, 1.04-1.62). Patients with heterosexual (1.78, 1.20-2.65) and IDU (1.58, 1.06-2.34) risk compared to MSM, and those with higher numbers of outpatient (1.03, 1.01-1.04) and inpatient (1.09, 1.01-1.19) visits were at greatest risk of unnecessary HCV testing. CONCLUSIONS Additional efforts to improve compliance with HCV testing guidelines are needed. Leveraging health information technology may increase HCV screening and reduce unnecessary testing.
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Affiliation(s)
- Baligh R Yehia
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States of America; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Ramin S Herati
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States of America
| | - John A Fleishman
- Center for Financing, Access, and Cost Trends, Agency for Healthcare Research and Quality, Rockville, Maryland, United States of America
| | - Joel E Gallant
- Southwest Care Center, Santa Fe, New Mexico, United States of America
| | - Allison L Agwu
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Stephen A Berry
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - P Todd Korthuis
- Department of Medicine, Oregon Health and Sciences University, Portland, Oregon, United States of America
| | - Richard D Moore
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Joshua P Metlay
- General Medicine Division, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Kelly A Gebo
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
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Momplaisir F, Yehia BR, Harhay MO, Fetzer B, Brady KA, Long JA. HIV testing trends: Southeastern Pennsylvania, 2002-2010. AIDS Patient Care STDS 2014; 28:303-10. [PMID: 24742326 DOI: 10.1089/apc.2014.0044] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
There are limited data on HIV testing trends after 2006 when the Centers for Disease Control and Prevention (CDC) introduced opt-out HIV testing with the aims of identifying HIV-infected persons early and linking them to care. We used data from the Southeastern Pennsylvania Household Health Survey between 2002 and 2010 to evaluate HIV testing over time. 50,698 adult (≥18 years) survey respondents were included. HIV testing increased after the CDC recommendations: 42.1% of survey respondents received testing at least once in 2002 versus 51.4% in 2010, p<0.001. Testing trends increased among all demographic groups, but existing differences in testing before 2006 persisted after that year as follows: younger patients, racial/ethnic minorities, patients on Medicaid were all more likely to get tested than their counterparts. Blacks and patients seeking care in community health centers had the fastest rise in HIV testing. The probability of HIV testing in Blacks was 0.56 (95% CI 0.54-0.60) in 2002 and increased to 0.73 (0.70-0.76) by 2010. Patients seeking care in community health centers had a probability of HIV testing of 0.57 (0.47-0.66) in 2002, which increased to 0.69 (0.60-0.77) by 2010. In comparison, patients in private clinics had an HIV testing probability of 0.40 (0.36-0.43) in 2002 compared to 0.47 (0.40-0.54) in 2010. HIV testing is increasing, particularly among ethnic minorities and in community health centers. However, testing remains to be improved in that setting and across all clinic types.
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Affiliation(s)
- Florence Momplaisir
- Section of Infectious Diseases, Temple University Hospital, Philadelphia, Pennsylvania
| | - Baligh R. Yehia
- Division of Infectious Diseases, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Michael O. Harhay
- Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Bradley Fetzer
- Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Kathleen A. Brady
- Philadelphia Department of Public Health, Philadelphia, Pennsylvania
| | - Judith A. Long
- Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
- Philadelphia VA Center for Health Equity Research and Promotion, Philadelphia, Pennsylvania
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Keller SC, Yehia BR, Momplaisir FO, Eberhart MG, Share A, Brady KA. Assessing the overall quality of health care in persons living with HIV in an urban environment. AIDS Patient Care STDS 2014; 28:198-205. [PMID: 24654969 DOI: 10.1089/apc.2014.0001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Ensuring high quality primary care for people living with HIV (PLWH) is important. We studied factors associated with meeting Health Resources and Services Administration-identified HIV performance measures, among a population-based sample of 376 PLWH in care at 24 Philadelphia clinics. Quality of care was assessed by a patient-level composite of 15 performance measures, focusing on HIV-specific care, vaccinations, and co-morbid condition screening. Adjusted incidence rate ratios (IRR) demonstrated relationships between patient and clinic factors and the performance measures score. The mean number of measures met was 8.52. Older age groups met more measures than 18- to 29-year-olds (age 40-49: adjusted IRR: 1.19, 95% CI: 1.05-1.35; age ≥50: adjusted IRR: 1.19, 95% CI: 1.03-1.35). Higher CD4 counts were associated with meeting more measures compared to CD4 <200 cells/μL (CD4 350-499 cells/μL: adjusted IRR: 1.14, 95% CI: 1.02-1.28; ≥500 cells/μL: adjusted IRR: 1.12, 95% CI: 1.01-1.26). PLWH attending clinics that provide adherence counseling or case management met more measures (adjusted IRR: 1.12, 95% CI: 1.04-1.21; adjusted IRR: 1.08, 95% CI: 1.02-1.14; respectively) than those attending clinics without these services. Limitations include potentially poor performance measure documentation and equal treatment of measures. Future work should focus on improving compliance with performance measures.
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Affiliation(s)
- Sara C. Keller
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Baligh R. Yehia
- Division of Infectious Diseases, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Florence O. Momplaisir
- Division of Infectious Diseases, Temple University School of Medicine, Philadelphia, Pennsylvania
| | - Michael G. Eberhart
- AIDS Activities Coordinating Office, City of Philadelphia Department of Public Health, Philadelphia, Pennsylvania
| | - Amanda Share
- AIDS Activities Coordinating Office, City of Philadelphia Department of Public Health, Philadelphia, Pennsylvania
| | - Kathleen A. Brady
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland
- AIDS Activities Coordinating Office, City of Philadelphia Department of Public Health, Philadelphia, Pennsylvania
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Yehia BR, Cronholm PF, Wilson N, Palmer SC, Sisson SD, Guilliames CE, Poll-Hunter NI, Sánchez JP. Mentorship and pursuit of academic medicine careers: a mixed methods study of residents from diverse backgrounds. BMC Med Educ 2014; 14:26. [PMID: 24512599 PMCID: PMC3922304 DOI: 10.1186/1472-6920-14-26] [Citation(s) in RCA: 106] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Accepted: 02/03/2014] [Indexed: 05/05/2023]
Abstract
BACKGROUND Mentorship influences career planning, academic productivity, professional satisfaction, and most notably, the pursuit of academic medicine careers. Little is known about the role of mentoring in recruiting Black/African American and Hispanic/Latino residents into academia. The objective of this study was to assess the influence of mentoring on academic medicine career choice among a cohort of racially and ethnically diverse residents. METHODS A strategic convenience sample of U.S. residents attending national professional conferences between March and July 2010; residents completed a quantitative survey and a subset participated in focus groups. RESULTS Of the 250 residents, 183 (73%) completed surveys and 48 participated in focus groups. Thirty-eight percent of residents were white, 31% Black/African American, 17% Asian/other, and 14% Hispanic/Latino. Most respondents (93%) reported that mentorship was important for entering academia, and 70% reported having sufficient mentorship to pursue academic careers. Three themes about mentorship emerged from focus groups: (1) qualities of successful mentorship models; (2) perceived benefits of mentorship; and (3) the value of racial/ethnic and gender concordance. Residents preferred mentors they selected rather than ones assigned to them, and expressed concern about faculty using checklists. Black/African American, Hispanic/Latino, and female residents described actively seeking out mentors of the same race/ethnicity and gender, but expressed difficulty finding such mentors. Lack of racial/ethnic concordance was perceived as an obstacle for minority mentees, requiring explanation of the context and nuances of their perspectives and situations to non-minority mentors. CONCLUSIONS The majority of residents in this study reported having access to mentors. However, data show that the lack of diverse faculty mentors may impede diverse residents' satisfaction and benefit from mentorship relationships compared to white residents. These findings are important for residency programs striving to enhance resident mentorship and for institutions working to diversify their faculty and staff to achieve institutional excellence.
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Affiliation(s)
- Baligh R Yehia
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
- 1309 Blockley Hall, 423 Guardian Drive, Philadelphia 19104, Pennsylvania
| | - Peter F Cronholm
- Department of Family Medicine and Community Health, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Nicholas Wilson
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Steven C Palmer
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Stephen D Sisson
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Conair E Guilliames
- Department of Family Medicine, Albert Einstein College of Medicine, Bronx, New York
| | - Norma I Poll-Hunter
- Diversity Policy and Programs, Association of American Medical Colleges, Washington, DC, USA
| | - John-Paul Sánchez
- Department of Emergency Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
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Yehia BR, Agwu AL, Schranz A, Korthuis PT, Gaur AH, Rutstein R, Sharp V, Spector SA, Berry SA, Gebo KA. Conformity of pediatric/adolescent HIV clinics to the patient-centered medical home care model. AIDS Patient Care STDS 2013; 27:272-9. [PMID: 23651104 DOI: 10.1089/apc.2013.0007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The patient-centered medical home (PCMH) has been introduced as a model for providing high-quality, comprehensive, patient-centered care that is both accessible and coordinated, and may provide a framework for optimizing the care of youth living with HIV (YLH). We surveyed six pediatric/adolescent HIV clinics caring for 578 patients (median age 19 years, 51% male, and 82% black) in July 2011 to assess conformity to the PCMH. Clinics completed a 50-item survey covering the six domains of the PCMH: (1) comprehensive care, (2) patient-centered care, (3) coordinated care, (4) accessible services, (5) quality and safety, and (6) health information technology. To determine conformity to the PCMH, a novel point-based scoring system was devised. Points were tabulated across clinics by domain to obtain an aggregate assessment of PCMH conformity. All six clinics responded. Overall, clinics attained a mean 75.8% [95% CI, 63.3-88.3%] on PCMH measures-scoring highest on patient-centered care (94.7%), coordinated care (83.3%), and quality and safety measures (76.7%), and lowest on health information technology (70.0%), accessible services (69.1%), and comprehensive care (61.1%). Clinics moderately conformed to the PCMH model. Areas for improvement include access to care, comprehensive care, and health information technology. Future studies are warranted to determine whether greater clinic PCMH conformity improves clinical outcomes and cost savings for YLH.
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Affiliation(s)
- Baligh R. Yehia
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Allison L. Agwu
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Asher Schranz
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - P. Todd Korthuis
- Department of Medicine, Oregon Health and Science University, Portland, Oregon
| | - Aditya H. Gaur
- Department of Infectious Diseases, St. Jude's Children's Research Hospital, Memphis, Tennessee
| | - Richard Rutstein
- Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Victoria Sharp
- HIV Center for Comprehensive Care, St. Luke's-Roosevelt Hospital, New York, New York
| | - Stephen A. Spector
- Department of Pediatrics, University of California San Diego, La Jolla, California, and Rady Children's Hospital San Diego, California
| | - Stephen A. Berry
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kelly A. Gebo
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Yehia BR, Mehta JM, Ciuffetelli D, Moore RD, Pham PA, Metlay JP, Gebo KA. Antiretroviral medication errors remain high but are quickly corrected among hospitalized HIV-infected adults. Clin Infect Dis 2012; 55:593-9. [PMID: 22610923 PMCID: PMC3520383 DOI: 10.1093/cid/cis491] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2012] [Accepted: 04/27/2012] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Antiretroviral therapy (ART) medication errors can lead to drug resistance, treatment failure, and death. Prior research suggests that ART medication errors are on the rise in US hospitals. This analysis provides a current estimate of inpatient antiretroviral prescribing errors. METHODS Retrospective review of medication orders during the first 48 hours of hospitalization for patients with human immunodeficiency virus (HIV) infection admitted to the Johns Hopkins Hospital between 1 January and 31 December 2009. Errors were classified as (1) incomplete regimen, (2) incorrect dosage, (3) incorrect schedule, and (4) nonrecommended drug-drug combinations. Multivariable regression was used to identify factors associated with errors. RESULTS A total of 702 admissions occurred in 2009. Of these, 380 had ART medications prescribed on the first day and 308 on the second day of hospitalization. A total of 145 ART medication errors in 110 admissions were identified on the first day (29%), and 22 errors were identified in 21 admissions on the second day (7%). The most common errors were incomplete regimen and incorrect dosage or schedule. Protease inhibitors accounted for the majority of dosing and scheduling errors (71%-73%). Compared with patients admitted to the HIV/AIDS service, those admitted to surgical services were at increased risk of errors (adjusted odds ratio, 3.10; 95% confidence interval, 1.18-8.18). CONCLUSIONS ART medication errors are common among hospitalized HIV-infected patients on the first day of admission, but most are corrected within 48 hours. Interventions are needed to safeguard patients and prevent serious complications of ART medication errors especially during the first 24 hours of hospitalization.
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Affiliation(s)
- Baligh R Yehia
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, 19104, USA.
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Affiliation(s)
- Baligh R Yehia
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, USA.
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Yehia BR, Long JA, Stearns CR, French B, Tebas P, Frank I. Impact of transitioning from HIV clinical trials to routine medical care on clinical outcomes and patient perceptions. AIDS Care 2011; 24:769-77. [DOI: 10.1080/09540121.2011.630368] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Affiliation(s)
- Baligh R. Yehia
- a Department of Medicine , University of Pennsylvania Perelman School of Medicine , Philadelphia , PA , USA
| | - Judith A. Long
- a Department of Medicine , University of Pennsylvania Perelman School of Medicine , Philadelphia , PA , USA
- b Philadelphia Veterans Affairs Center for Health Equity Research and Promotion , Philadelphia , PA , USA
| | - Cordelia R. Stearns
- a Department of Medicine , University of Pennsylvania Perelman School of Medicine , Philadelphia , PA , USA
| | - Benjamin French
- c Department of Biostatistics and Epidemiology , University of Pennsylvania Perelman School of Medicine , Philadelphia , PA , USA
| | - Pablo Tebas
- a Department of Medicine , University of Pennsylvania Perelman School of Medicine , Philadelphia , PA , USA
| | - Ian Frank
- a Department of Medicine , University of Pennsylvania Perelman School of Medicine , Philadelphia , PA , USA
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Yehia BR, Fleishman JA, Wilson L, Hicks PL, Gborkorquellie TT, Gebo KA. Incidence of and risk factors for bacteraemia in HIV-infected adults in the era of highly active antiretroviral therapy. HIV Med 2011; 12:535-43. [PMID: 21429066 DOI: 10.1111/j.1468-1293.2011.00919.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND HIV-infected patients have an increased risk for bacteraemia compared with HIV-negative patients. Few data exist on the incidence of and risk factors for bacteraemia across time in the current era of highly active antiretroviral therapy (HAART). METHODS We assessed the incidence of bacteraemia among patients followed between 2000 and 2008 at 10 HIV Research Network sites. This large multisite, multistate clinical cohort study collected demographic, clinical and therapeutic data longitudinally. International Statistical Classification of Diseases and Related Health Problems (ICD)-9 codes were examined to identify all cases of in-patient bacteraemia. Logistic regression analysis was used to assess risk factors for bacteraemia and trends over time in the odds of bacteraemia. RESULTS A total of 39 318 patients were followed for 146 289 person-years (PY). During the study period, there were 2025 episodes of bacteraemia (incidence 13.8 events/1000 PY). The most common bacteraemia diagnosis was 'bacteraemia, not otherwise specified (NOS)' (51%) followed by Staphylococcus aureus (16%) and Streptococcus species (6.5%). In multivariate analysis, the likelihood of bacteraemia was found to have increased in 2005-2008, compared with 2000. Other factors associated with higher odds of bacteraemia included a history of injection drug use (IDU), age ≥ 50 years, Black race and greater immunosuppression. CONCLUSIONS The likelihood of bacteraemia has risen slightly in recent years. Patients who are Black or have a history of IDU are at higher risk. Further research is needed to identify reasons for this increase and to evaluate programmes designed to reduce the bacteraemia risk.
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Affiliation(s)
- B R Yehia
- Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA.
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Abstract
Mycobacterium tuberculosis can cause significant infections in liver transplant candidates and recipients. Its nonspecific clinical features and prolonged growth time in culture make the diagnosis difficult, and treating tuberculosis (TB) remains challenging because of significant toxicities and drug-drug interactions. The diagnosis of a latent TB infection may be accomplished with tuberculin skin testing and with the newer interferon-γ release assays, although this infection may be underrecognized because of host factors. Latent TB should be treated, but the degree of liver failure and the likelihood of progression to active TB will dictate whether this should occur before or after transplantation. Patients who have a history of TB, have used muromonab-CD3 or anti-T lymphocyte antibodies, or have experienced allograft rejection or coinfection with cytomegalovirus, Pneumocystis jiroveci, or Nocardia are at the greatest risk of developing active TB. Active TB in transplant patients is difficult to treat because of drug-induced hepatotoxicity and the significant interaction between rifampin and calcineurin inhibitors. In this article, we review the epidemiology, clinical features, and evaluation of transplant candidates and recipients. In addition, we offer recommendations on the appropriate diagnostic and treatment regimens for patients with latent and active TB infections.
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Affiliation(s)
- Baligh R Yehia
- Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA.
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Yehia BR, Gebo KA, Hicks PB, Korthuis PT, Moore RD, Ridore M, Mathews WC. Structures of care in the clinics of the HIV Research Network. AIDS Patient Care STDS 2008; 22:1007-13. [PMID: 19072107 DOI: 10.1089/apc.2008.0093] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
As the HIV epidemic has evolved to become a chronic, treatable condition the focus of HIV care has shifted from the inpatient to the outpatient arena. The optimal structure of HIV care in the outpatient setting is unknown. Using the HIV Research Network (HIVRN), a federally sponsored consortium of 21 sites that provide care to HIV-infected individuals, this study attempted to: (1) document key features of the organization of care in HIVRN adult clinics and (2) estimate variability among clinics in these parameters. A cross-sectional survey of adult clinic directors regarding patient volume, follow-up care, provider characteristics, acute patient care issues, wait times, patient safety procedures, and prophylaxis practices was conducted from July to December 2007. All 15 adult HIVRN clinic sites responded: 9 academic and 6 community-based. The results demonstrate variability in key practice parameters. Median (range) of selected practice characteristics were: (1) annual patient panel size, 1300 (355-5600); (2) appointment no-show rate, 28% (8%-40%); (3) annual loss to follow-up, 15% (5%-25%); (4) wait time for new appointments, 5 days (0.5-22.5), and follow-up appointment, 8 days (0-30). The majority of clinics had an internal mechanism to handle acute patient care issues and provide a number of onsite consultative services. Nurse practitioners and physician assistants were highly utilized. These data will facilitate improvements in chronic care management of persons living with HIV.
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Jones HC, Chen GF, Yehia BR, Carter BJ, Akins EJ, Wolpin LC. Single and multiple congenic strains for hydrocephalus in the H-Tx rat. Mamm Genome 2005; 16:251-61. [PMID: 15965786 PMCID: PMC2929525 DOI: 10.1007/s00335-004-2390-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2004] [Accepted: 12/06/2004] [Indexed: 11/25/2022]
Abstract
The H-Tx rat has fetal-onset hydrocephalus with a complex mode of inheritance. Previously, quantitative trait locus mapping using a backcross with Fischer F344 rats demonstrated genetic loci significantly linked to hydrocephalus on Chromosomes 10, 11, and 17. Hydrocephalus was preferentially associated with heterozygous alleles on Chrs 10 and 11 and with homozygous alleles on Chr 17. This study aimed to determine the phenotypic contribution of each locus by constructing single and multiple congenic strains. Single congenic rats were constructed using Fischer F344 as the recipient strain and a marker-assisted protocol. The homozygous strains were maintained for eight generations and the brains examined for dilated ventricles indicative for hydrocephalus. No congenic rats had severe (overt) hydrocephalus. A few pups and a significant number of adults had mild disease. The incidence was significantly higher in the C10 and C17 congenic strains than in the nonhydrocephalic F344 strain. Breeding to F344 to make F.H-Tx C10 or C11 rats heterozygous for the hydrocephalus locus failed to produce progeny with severe disease. Both bicongenic and tricongenic rats of different genotype combinations were constructed by crossing congenic rats. None had severe disease but the frequency of mild hydrocephalus in adults was similar to congenic rats and significantly higher than in the F344 strain. Rats with severe hydrocephalus were recovered in low numbers when single congenic or bicongenic rats were crossed with the parental H-Tx strain. It is concluded that the genetic and epigenetic factors contributing to severe hydrocephalus in the H-Tx strain are more complex than originally anticipated.
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Affiliation(s)
- Hazel C Jones
- Department of Pharmacology and Therapeutics, University of Florida, Gainesville, Florida, 32610-0267, USA.
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