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Stringfellow EJ, Lim TY, DiGennaro C, Zhang Z, Paramasivam P, Bearnot B, Humphreys K, Jalali MS. Long-Term Effects of Increasing Buprenorphine Treatment Seeking, Duration, and Capacity on Opioid Overdose Fatalities: A Model-based Analysis. J Addict Med 2023; 17:439-446. [PMID: 37579104 PMCID: PMC10460819 DOI: 10.1097/adm.0000000000001153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 02/18/2023]
Abstract
OBJECTIVES Because buprenorphine treatment of opioid use disorder reduces opioid overdose deaths (OODs), expanding access to care is an important policy and clinical care goal. Policymakers must choose within capacity limitations whether to expand the number of people with opioid use disorder who are treated or extend duration for existing patients. This inherent tradeoff could be made less acute with expanded buprenorphine treatment capacity. METHODS To inform such decisions, we used a validated simulation model to project the effects of increasing buprenorphine treatment-seeking, average episode duration, and capacity (patients per provider) on OODs in the United States from 2023 to 2033, varying the start time to assess the effects of implementation delays. RESULTS Results show that increasing treatment duration alone could cost lives in the short term by reducing capacity for new admissions yet save more lives in the long term than accomplished by only increasing treatment seeking. Increasing provider capacity had negligible effects. The most effective 2-policy combination was increasing capacity and duration simultaneously, which would reduce OODs up to 18.6% over a decade. By 2033, the greatest reduction in OODs (≥20%) was achieved when capacity was doubled and average duration reached 2 years, but only if the policy changes started in 2023. Delaying even a year diminishes the benefits. Treatment-seeking increases were equally beneficial whether they began in 2023 or 2025 but of only marginal benefit beyond what capacity and duration achieved. CONCLUSIONS If policymakers only target 2 policies to reduce OODs, they should be to increase capacity and duration, enacted quickly and aggressively.
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Affiliation(s)
| | - Tse Yang Lim
- Sloan School of Management, Massachusetts Institute of Technology, Cambridge, MA
- Harvard T.H. Chan School of Public Health, Boston, MA
| | - Catherine DiGennaro
- Sloan School of Management, Massachusetts Institute of Technology, Cambridge, MA
| | - Ziyuan Zhang
- Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | | | - Benjamin Bearnot
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA
| | - Keith Humphreys
- Veterans Affairs and Stanford University Medical Centers, Palo Alto, CA
| | - Mohammad S. Jalali
- Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Sloan School of Management, Massachusetts Institute of Technology, Cambridge, MA
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Claypool AL, DiGennaro C, Russell WA, Yildirim MF, Zhang AF, Reid Z, Stringfellow EJ, Bearnot B, Schackman BR, Humphreys K, Jalali MS. Cost-effectiveness of Increasing Buprenorphine Treatment Initiation, Duration, and Capacity Among Individuals Who Use Opioids. JAMA Health Forum 2023; 4:e231080. [PMID: 37204803 PMCID: PMC10199347 DOI: 10.1001/jamahealthforum.2023.1080] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 03/26/2023] [Indexed: 05/20/2023] Open
Abstract
Importance Buprenorphine is an effective and cost-effective medication to treat opioid use disorder (OUD), but is not readily available to many people with OUD in the US. The current cost-effectiveness literature does not consider interventions that concurrently increase buprenorphine initiation, duration, and capacity. Objective To conduct a cost-effectiveness analysis and compare interventions associated with increased buprenorphine treatment initiation, duration, and capacity. Design and Setting This study modeled the effects of 5 interventions individually and in combination using SOURCE, a recent system dynamics model of prescription opioid and illicit opioid use, treatment, and remission, calibrated to US data from 1999 to 2020. The analysis was run during a 12-year time horizon from 2021 to 2032, with lifetime follow-up. A probabilistic sensitivity analysis on intervention effectiveness and costs was conducted. Analyses were performed from April 2021 through March 2023. Modeled participants included people with opioid misuse and OUD in the US. Interventions Interventions included emergency department buprenorphine initiation, contingency management, psychotherapy, telehealth, and expansion of hub-and-spoke narcotic treatment programs, individually and in combination. Main Outcomes and Measures Total national opioid overdose deaths, quality-adjusted life years (QALYs) gained, and costs from the societal and health care perspective. Results Projections showed that contingency management expansion would avert 3530 opioid overdose deaths over 12 years, more than any other single-intervention strategy. Interventions that increased buprenorphine treatment duration initially were associated with an increased number of opioid overdose deaths in the absence of expanded treatment capacity. With an incremental cost- effectiveness ratio of $19 381 per QALY gained (2021 USD), the strategy that expanded contingency management, hub-and-spoke training, emergency department initiation, and telehealth was the preferred strategy for any willingness-to-pay threshold from $20 000 to $200 000/QALY gained, as it was associated with increased treatment duration and capacity simultaneously. Conclusion and Relevance This modeling analysis simulated the effects of implementing several intervention strategies across the buprenorphine cascade of care and found that strategies that were concurrently associated with increased buprenorphine treatment initiation, duration, and capacity were cost-effective.
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Affiliation(s)
- Anneke L. Claypool
- Massachusetts General Hospital Institute for Technology Assessment, Harvard Medical School, Boston
| | - Catherine DiGennaro
- Massachusetts General Hospital Institute for Technology Assessment, Harvard Medical School, Boston
| | - W. Alton Russell
- Massachusetts General Hospital Institute for Technology Assessment, Harvard Medical School, Boston
- School of Population and Global Health, McGill University, Montreal, Quebec, Canada
| | - Melike F. Yildirim
- Massachusetts General Hospital Institute for Technology Assessment, Harvard Medical School, Boston
| | - Alan F. Zhang
- Massachusetts General Hospital Institute for Technology Assessment, Harvard Medical School, Boston
| | - Zuri Reid
- Massachusetts General Hospital Institute for Technology Assessment, Harvard Medical School, Boston
| | - Erin J. Stringfellow
- Massachusetts General Hospital Institute for Technology Assessment, Harvard Medical School, Boston
| | - Benjamin Bearnot
- Division of General Internal Medicine, Massachusetts General Hospital, Boston
| | - Bruce R. Schackman
- Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
| | - Keith Humphreys
- Veterans Affairs and Stanford University Medical Centers, Palo Alto, California
| | - Mohammad S. Jalali
- Massachusetts General Hospital Institute for Technology Assessment, Harvard Medical School, Boston
- MIT Sloan School of Management, Cambridge, Massachusetts
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Dong H, Stringfellow EJ, Russell WA, Bearnot B, Jalali MS. Impact of Alternative Ways to Operationalize Buprenorphine Treatment Duration on Understanding Continuity of Care for Opioid Use Disorder. Int J Ment Health Addict 2022. [DOI: 10.1007/s11469-022-00985-w] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
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Morales Y, Smyth E, Zubiago J, Bearnot B, Wurcel AG. "They Just Assume That We're All Going to Do the Wrong Thing With It. It's Just Not True": Stakeholder Perspectives About Peripherally Inserted Central Catheters in People Who Inject Drugs. Open Forum Infect Dis 2022; 9:ofac364. [PMID: 36267246 PMCID: PMC9579457 DOI: 10.1093/ofid/ofac364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 07/21/2022] [Indexed: 11/13/2022] Open
Abstract
Background In the absence of adequate harm reduction opportunities, people who inject drugs (PWID) are at increased risk for serious infections. Infectious diseases guidelines recommend extended periods of intravenous antibiotic treatment through peripherally inserted central catheters (PICCs), but PWID are often deemed unsuitable for this treatment. We conducted semi-structured interviews and focus groups to understand the perspectives and opinions of patients and clinicians on the use of PICCs for PWID. Methods We approached patients and clinicians (doctors, nurses, PICC nurses, social workers, and case workers) involved in patient care at Tufts Medical Center (Boston, Massachusetts) between August 2019 and April 2020 for semi-structured interviews and focus groups. Results Eleven of 14 (79%) patients agreed to participate in an in-depth interview, and 5 role-specific clinician focus groups (1 group consisting of infectious diseases, internal medicine, and addiction psychiatry doctors, 2 separate groups of floor nurses, 1 group of PICC nurses, and 1 group of social workers) were completed. Emergent themes included the overall agreement that PICCs improve healthcare, patients' feelings that their stage of recovery from addiction was not taken into consideration, and clinicians' anecdotal negative experiences driving decisions on PICCs. Conclusions When analyzed together, the experiences of PWID and clinicians shed light on ways the healthcare system can improve the quality of care for PWID hospitalized for infections. Further research is needed to develop a system of person-centered care for PWID that meets the specific needs of patients and improves the relationship between them and the healthcare system.
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Affiliation(s)
- Yoelkys Morales
- Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Emma Smyth
- Division of Geographic Medicine and Infectious Diseases, Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Julia Zubiago
- Division of Geographic Medicine and Infectious Diseases, Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Benjamin Bearnot
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA,Harvard Medical School, Boston, Massachusetts, USA
| | - Alysse G Wurcel
- Correspondence: Alysse G. Wurcel, MD, MS, Tufts Medical Center, Department of Geographic Medicine and Infectious Diseases, 800 Washington St, Boston MA 02111, USA ()
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Stringfellow EJ, Lim TY, Humphreys K, DiGennaro C, Stafford C, Beaulieu E, Homer J, Wakeland W, Bearnot B, McHugh RK, Kelly J, Glos L, Eggers SL, Kazemi R, Jalali MS. Reducing opioid use disorder and overdose deaths in the United States: A dynamic modeling analysis. Sci Adv 2022; 8:eabm8147. [PMID: 35749492 PMCID: PMC9232111 DOI: 10.1126/sciadv.abm8147] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
Opioid overdose deaths remain a major public health crisis. We used a system dynamics simulation model of the U.S. opioid-using population age 12 and older to explore the impacts of 11 strategies on the prevalence of opioid use disorder (OUD) and fatal opioid overdoses from 2022 to 2032. These strategies spanned opioid misuse and OUD prevention, buprenorphine capacity, recovery support, and overdose harm reduction. By 2032, three strategies saved the most lives: (i) reducing the risk of opioid overdose involving fentanyl use, which may be achieved through fentanyl-focused harm reduction services; (ii) increasing naloxone distribution to people who use opioids; and (iii) recovery support for people in remission, which reduced deaths by reducing OUD. Increasing buprenorphine providers' capacity to treat more people decreased fatal overdose, but only in the short term. Our analysis provides insight into the kinds of multifaceted approaches needed to save lives.
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Affiliation(s)
| | - Tse Yang Lim
- Sloan School of Management, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Keith Humphreys
- Veterans Affairs and Stanford University Medical Centers, Palo Alto, CA, USA
| | | | | | | | - Jack Homer
- Sloan School of Management, Massachusetts Institute of Technology, Cambridge, MA, USA
- Homer Consulting, Barrytown, NY, USA
| | - Wayne Wakeland
- Systems Science Program, Portland State University, Portland, OR, USA
| | - Benjamin Bearnot
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - R. Kathryn McHugh
- Division of Alcohol, Drugs, and Addiction, McLean Hospital, Harvard Medical School, Boston, MA, USA
| | - John Kelly
- Center for Addiction Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Lukas Glos
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - Sara L. Eggers
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - Reza Kazemi
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - Mohammad S. Jalali
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Sloan School of Management, Massachusetts Institute of Technology, Cambridge, MA, USA
- Corresponding author.
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Streck JM, Regan S, Neil J, Kalkhoran S, Gupta PS, Bearnot B, Coker FK, Kalagher KM, Park ER, Wakeman S, Rigotti NA. Interest in Electronic Cigarettes for Smoking Cessation Among Adults With Opioid Use Disorder in Buprenorphine Treatment: A Mixed-Methods Investigation. Nicotine Tob Res 2022; 24:1134-1138. [PMID: 34915581 PMCID: PMC9199932 DOI: 10.1093/ntr/ntab259] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 10/13/2021] [Accepted: 12/14/2021] [Indexed: 11/14/2022]
Abstract
INTRODUCTION Individuals in treatment for opioid use disorder (OUD) have high smoking rates and limited success with Food and Drug Administration (FDA)-approved cessation aids, suggesting need for novel approaches. Electronic cigarettes (e-cigarettes) might benefit this population, but e-cigarettes' acceptability for tobacco reduction or cessation among smokers in OUD treatment is not known. METHODS A cross-sectional mixed-methods study of 222 adults in OUD treatment with buprenorphine in the Boston, Massachusetts metropolitan area was conducted in 2020. We used quantitative and qualitative data to investigate individuals' experience with and interest in e-cigarettes and other methods for smoking cessation and assessed factors associated with interest in e-cigarette use. RESULTS One hundred sixty (72%) of the 222 participants were past 30-day cigarette smokers. They most frequently reported having ever used nicotine replacement therapy (NRT; 83%) and e-cigarettes (71%) for smoking cessation and most often indicated interest in using NRT (71%) and e-cigarettes (44%) for future smoking cessation. In multiple logistic regression analysis, interest in using e-cigarettes for future smoking cessation was independently associated with having ever used e-cigarettes for smoking cessation, current e-cigarette use, and perceiving e-cigarettes to be less harmful than cigarettes (ps < .05). In qualitative data, many current vapers/former smokers reported that e-cigarettes had been helpful for quitting cigarettes. For current smokers who currently or formerly vaped, frequently reported challenges in switching to e-cigarettes were concerns about replacing one addiction with another and e-cigarettes not adequately substituting for cigarettes. CONCLUSIONS E-cigarettes had a moderate level of acceptability for smoking cessation among cigarette smokers in OUD treatment. More research is warranted to test the efficacy of this approach. IMPLICATIONS Individuals in treatment for opioid use disorder (OUD) have high smoking rates and limited success with existing smoking cessation tools, suggesting a need for novel cessation treatment approaches. In this mixed-methods study of individuals receiving medication treatment for OUD with buprenorphine in Massachusetts in 2020, we found a moderate level of acceptability of e-cigarettes for smoking cessation.
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Affiliation(s)
- Joanna M Streck
- Tobacco Research and Treatment Center, Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston MA, USA
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Susan Regan
- Tobacco Research and Treatment Center, Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston MA, USA
| | - Jordan Neil
- Department of Family and Preventive Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Health Promotion Research Center, Stephenson Cancer Center, Oklahoma City, OK, USA
| | - Sara Kalkhoran
- Tobacco Research and Treatment Center, Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston MA, USA
| | - Priya S Gupta
- Tobacco Research and Treatment Center, Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston MA, USA
| | - Benjamin Bearnot
- Tobacco Research and Treatment Center, Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston MA, USA
| | - Faith K Coker
- Tobacco Research and Treatment Center, Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston MA, USA
| | - Kelly M Kalagher
- Tobacco Research and Treatment Center, Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston MA, USA
| | - Elyse R Park
- Tobacco Research and Treatment Center, Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston MA, USA
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Sarah Wakeman
- Tobacco Research and Treatment Center, Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston MA, USA
| | - Nancy A Rigotti
- Tobacco Research and Treatment Center, Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston MA, USA
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Vyas DA, Marinacci L, Bearnot B, Wakeman SE, Sundt TM, Jassar AS, Triant VA, Nelson SB, Dudzinski DM, Paras ML. Creation of a Multidisciplinary Drug Use Endocarditis Treatment (DUET) Team: Initial Patient Characteristics, Outcomes, and Future Directions. Open Forum Infect Dis 2022; 9:ofac047. [PMID: 35252467 PMCID: PMC8890495 DOI: 10.1093/ofid/ofac047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 11/01/2021] [Accepted: 01/30/2022] [Indexed: 11/17/2022] Open
Abstract
Background Consensus guidelines recommend multidisciplinary models to manage infective endocarditis, yet often do not address the unique challenges of treating people with drug use–associated infective endocarditis (DUA-IE). Our center is among the first to convene a Drug Use Endocarditis Treatment (DUET) team composed of specialists from Infectious Disease, Cardiothoracic Surgery, Cardiology, and Addiction Medicine. Methods The objective of this study was to describe the demographics, infectious characteristics, and clinical outcomes of the first cohort of patients cared for by the DUET team. This was a retrospective chart review of patients referred to the DUET team between August 2018 and May 2020 with DUA-IE. Results Fifty-seven patients were presented to the DUET team between August 2018 and May 2020. The cohort was young, with a median age of 35, and injected primarily opioids (82.5% heroin/fentanyl), cocaine (52.6%), and methamphetamine (15.8%). Overall, 14 individuals (24.6%) received cardiac surgery, and the remainder (75.4%) were managed with antimicrobial therapy alone. Nearly 65% of individuals were discharged on medication for opioid use disorder, though less than half (36.8%) were discharged with naloxone and only 1 patient was initiated on HIV pre-exposure prophylaxis. Overall, the cohort had a high rate of readmission (42.1%) within 90 days of discharge. Conclusions Multidisciplinary care models such as the DUET team can help integrate nuanced decision-making from numerous subspecialties. They can also increase the uptake of addiction medicine and harm reduction tools, but further efforts are needed to integrate harm reduction strategies and improve follow-up in future iterations of the DUET team model.
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Affiliation(s)
- Darshali A Vyas
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Division of General Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lucas Marinacci
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Benjamin Bearnot
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Division of General Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sarah E Wakeman
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Division of General Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Thoralf M Sundt
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
- Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Arminder S Jassar
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
- Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Virginia A Triant
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Division of General Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sandra B Nelson
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - David M Dudzinski
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Molly L Paras
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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Kimmel SD, Rosenmoss S, Bearnot B, Weinstein Z, Yan S, Walley AY, Larochelle MR. Northeast Postacute Medical Facilities Disproportionately Reject Referrals For Patients With Opioid Use Disorder. Health Aff (Millwood) 2022; 41:434-444. [PMID: 35254930 PMCID: PMC10775137 DOI: 10.1377/hlthaff.2021.01242] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [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: 11/05/2022]
Abstract
Referrals of hospitalized patients with opioid use disorder (OUD) to postacute medical care facilities are commonly rejected. We linked all electronic referrals from a Boston safety-net hospital in 2018 to clinical data and used multivariable logistic regression to examine the association between OUD diagnosis and rejection from postacute medical care. Hospitalized patients with OUD were referred to more facilities than patients without OUD (8.2 versus 6.6 per hospitalization), were rejected a greater proportion of the time (83.3 percent versus 65.5 percent), and in adjusted analyses had greater odds of rejection from postacute care (adjusted odds ratio, 2.2). In addition, people with OUD were referred disproportionately to a small subset of facilities with a higher likelihood of acceptance. Our findings document disparities in postacute care admissions for people with OUD. Efforts to ensure equitable access to medically necessary postacute medical care for people with OUD are needed.
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Affiliation(s)
- Simeon D Kimmel
- Simeon D. Kimmel , Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Sophie Rosenmoss
- Sophie Rosenmoss, Boston University School of Medicine and Boston Medical Center
| | - Benjamin Bearnot
- Benjamin Bearnot, Massachusetts General Hospital, Boston, Massachusetts
| | - Zoe Weinstein
- Zoe Weinstein, Boston University School of Medicine and Boston Medical Center
| | | | - Alexander Y Walley
- Alexander Y. Walley, Boston University School of Medicine and Boston Medical Center
| | - Marc R Larochelle
- Marc R. Larochelle, Boston University School of Medicine and Boston Medical Center
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Streck JM, Regan S, Kalkhoran S, Kalagher KM, Bearnot B, Gupta PS, Wakeman S, Rigotti NA. Perceptions of E-cigarettes among adults in treatment for opioid use disorder. Drug Alcohol Depend Rep 2022; 2:100023. [PMID: 36845890 PMCID: PMC9949332 DOI: 10.1016/j.dadr.2022.100023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 01/03/2022] [Accepted: 01/05/2022] [Indexed: 10/19/2022]
Abstract
Background Individuals with opioid use disorder (OUD) have a high prevalence of smoking and limited success quitting smoking with existing tools. There is ongoing debate about whether electronic cigarettes (e-cigarettes) may be a viable harm reduction strategy. We sought to determine the potential acceptability of e-cigarettes for cigarette harm reduction among individuals receiving medication treatment for opioid use disorder (MOUD) with buprenorphine. Among individuals receiving MOUD we investigated health harm perceptions of cigarettes, nicotine e-cigarettes, and nicotine replacement therapy (NRT), and perceptions of the helpfulness of e-cigarettes and NRT for quitting cigarettes. Methods Cross-sectional telephone survey conducted among adults in buprenorphine treatment at five community health centers in the Boston, MA metropolitan area from February to July 2020. Results 93% and 63% of participants rated cigarettes and e-cigarettes, respectively, as very or extremely harmful to health, and 62% rated NRT as not to slightly harmful to health. Over half (58%) rated cigarettes as more harmful than e-cigarettes; 65% and 83% perceived e-cigarettes and NRT, respectively, to be helpful for reducing/quitting cigarette use. In bivariate analyses, nicotine e-cigarette users, compared to nonusers, perceived e-cigarettes to be less harmful to health and more often rated e-cigarettes as helpful for reducing/quitting cigarette use (both p<0.05). Conclusions This study suggests that Massachusetts patients receiving MOUD with buprenorphine have concerns about the health harms of e-cigarettes yet rate them as helpful tools for reducing or quitting cigarette smoking. Future research is needed to test the efficacy of e-cigarettes for cigarette harm reduction.
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Affiliation(s)
- Joanna M. Streck
- Tobacco Research and Treatment Center, Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Susan Regan
- Tobacco Research and Treatment Center, Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Sara Kalkhoran
- Tobacco Research and Treatment Center, Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Kelly M. Kalagher
- Tobacco Research and Treatment Center, Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Benjamin Bearnot
- Tobacco Research and Treatment Center, Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Priya S. Gupta
- Tobacco Research and Treatment Center, Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Sarah Wakeman
- Tobacco Research and Treatment Center, Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Nancy A. Rigotti
- Tobacco Research and Treatment Center, Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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Streck JM, Parker MA, Bearnot B, Kalagher K, Sigmon SC, Goodwin RD, Weinberger AH. National Trends in Suicide Thoughts and Behavior among US Adults with Opioid Use Disorder from 2015 to 2020. Subst Use Misuse 2022; 57:876-885. [PMID: 35232317 PMCID: PMC9084338 DOI: 10.1080/10826084.2022.2046102] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Suicide thoughts and behavior (STB) are associated with premature mortality and is disproportionately represented among those with opioid use disorder (OUD). Recent trends in STB among those with OUD are lacking. We investigated trends in STB among US adults with versus without OUD using six waves of cross-sectional, nationally-representative, epidemiological data. METHODS Data came from the 2015-2020 National Survey on Drug Use and Health (combined n = 241,675). We compared past-year STB outcomes (i.e., thoughts of seriously considering killing self (SI), suicide plan (SP), suicide attempt (SA)) among adults with versus without past-year OUD. Unadjusted and adjusted logistic regression tested the association between survey-year and past-year STB outcomes (i.e., SI, SP/SA) stratified by OUD status. RESULTS Between 2015 and 2020, 26% versus 4% of those with and without OUD, respectively, reported SI, 10% versus 1% reported a SP, and 6% versus 1% reported SA (all ps < 0.001). In adjusted analyses, across survey years, no changes in the prevalence of SI were observed for adults with or without OUD, and no changes were observed over time for SP/SA in adults with or without OUD. OUD severity and treatment status did not moderate the relationship between OUD and STB outcomes. CONCLUSIONS Among US adults, OUD was associated with thoughts of suicide and suicide behavior. The heightened prevalence of STB in adults with OUD has not changed in recent years. Screening for SI is needed among those reporting opioid misuse and should be routinely integrated into OUD prevention and treatment.
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Affiliation(s)
- Joanna M Streck
- Tobacco Research and Treatment Center, Division of General Internal Medicine (DGIM), Department of Medicine, Massachusetts General Hospital (MGH)/Harvard Medical School (HMS), Boston, Massachusetts, USA.,Department of Psychiatry, MGH/HMS, Boston, Massachusetts, USA
| | - Maria A Parker
- Department of Epidemiology & Biostatistics, School of Public Health-Bloomington, Indiana University, Bloomington, Indiana, USA
| | - Benjamin Bearnot
- Tobacco Research and Treatment Center, Division of General Internal Medicine (DGIM), Department of Medicine, Massachusetts General Hospital (MGH)/Harvard Medical School (HMS), Boston, Massachusetts, USA
| | - Kelly Kalagher
- Tobacco Research and Treatment Center, Division of General Internal Medicine (DGIM), Department of Medicine, Massachusetts General Hospital (MGH)/Harvard Medical School (HMS), Boston, Massachusetts, USA
| | - Stacey C Sigmon
- Department of Psychiatry, Vermont Center on Behavior & Health, University of Vermont, Burlington, Vermont, USA
| | - Renee D Goodwin
- Mailman School of Public Health, Columbia University, New York, New York, USA.,Department of Epidemiology and Biostatistics, Graduate School of Public Health and Health Policy, The City University of New York, New York, New York, USA
| | - Andrea H Weinberger
- Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, New York, USA.,Albert Einstein College of Medicine, Bronx, New York, USA
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11
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Streck JM, Regan S, Bearnot B, Gupta PS, Kalkhoran S, Kalagher KM, Wakeman S, Rigotti NA. Prevalence of Cannabis Use and Cannabis Route of Administration among Massachusetts Adults in Buprenorphine Treatment for Opioid Use Disorder. Subst Use Misuse 2022; 57:1104-1110. [PMID: 35410577 PMCID: PMC10091221 DOI: 10.1080/10826084.2022.2063899] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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] [Indexed: 10/18/2022]
Abstract
BACKGROUND Recent prevalence estimates of cannabis use among individuals receiving medication treatment for OUD (MOUD) are lacking, and no study has characterized cannabis route of administration (cROA) in this population. These knowledge gaps are relevant because cannabis' effects and health outcomes vary by cROA and the availability and perceptions of cROA (e.g., vaping devices) are changing. METHODS The Vaping In Buprenorphine-treated patients Evaluation (VIBE) cross-sectional survey assessed the prevalence and correlates of cannabis use and cROA among adults receiving buprenorphine MOUD from 02/20 to 07/20 at five community health centers in Massachusetts, a state with legal recreational and medical cannabis use. RESULTS Among the 92/222 (41%) respondents reporting past 30-day cannabis use, smoking was the most common cROA (75%), followed by vaping (38%), and eating (26%). Smoking was more often used as a single cROA vs. in combination others (p = 0.01), whereas vaping, eating, and dabbing were more often used in combination with another cROA (all p < 0.05). Of the 39% of participants reporting multiple cROA, smoking and vaping (61%), and smoking and eating (50%), were the most prevalent combinations. Nonwhite race (vs. white) and current cigarette smoking (vs. no nicotine use) were associated with past 30-day cannabis use in multiple logistic regression. CONCLUSIONS Prevalence of past 30-day cannabis use among individuals receiving buprenorphine MOUD in Massachusetts in 2020 was nearly double the prevalence of cannabis use in Massachusetts' adult general population in 2019 (21%). Our data are consistent with state and national data showing smoking as the most common cROA.
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Affiliation(s)
- Joanna M Streck
- Tobacco Research and Treatment Center, Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Susan Regan
- Tobacco Research and Treatment Center, Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Benjamin Bearnot
- Tobacco Research and Treatment Center, Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Priya S Gupta
- Tobacco Research and Treatment Center, Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Sara Kalkhoran
- Tobacco Research and Treatment Center, Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Kelly M Kalagher
- Tobacco Research and Treatment Center, Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sarah Wakeman
- Tobacco Research and Treatment Center, Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Nancy A Rigotti
- Tobacco Research and Treatment Center, Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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12
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Streck JM, Kalkhoran S, Bearnot B, Gupta PS, Kalagher KM, Regan S, Wakeman S, Rigotti NA. Perceived risk, attitudes, and behavior of cigarette smokers and nicotine vapers receiving buprenorphine treatment for opioid use disorder during the COVID-19 pandemic. Drug Alcohol Depend 2021; 218:108438. [PMID: 33271434 PMCID: PMC7687365 DOI: 10.1016/j.drugalcdep.2020.108438] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 11/09/2020] [Accepted: 11/21/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Cigarette smoking may increase the risk of COVID-19 complications, reinforcing the urgency of smoking cessation in populations with high smoking prevalence such as individuals with opioid use disorder (OUD). Whether the COVID-19 pandemic has altered perceptions, motivation to quit, or tobacco use among cigarette smokers and nicotine e-cigarette vapers with OUD is unknown. METHODS A telephone survey was conducted in March-July 2020 of current cigarette smokers or nicotine vapers with OUD who were stable on buprenorphine treatment at five Boston (MA) area community health centers. The survey assessed respondents' perceived risk of COVID-19 due to smoking or vaping, interest in quitting, quit attempts and change in tobacco consumption during the pandemic. RESULTS 222/520 patients (43 %) completed the survey, and 145 were asked questions related to COVID-19. Of these, 61 % smoked cigarettes only, 13 % vaped nicotine only, and 26 % were dual users. Nearly 80 % of participants believed that smoking and vaping increased their risk of COVID-19 infection or complications. Smokers with this belief reported an increased interest in quitting (AOR 4.6, 95 % CI:1.7-12.4). Overall, 49 % of smokers and 42 % of vapers reported increased interest in quitting due to the pandemic; 24 % and 20 %, respectively, reported attempting to quit since the pandemic. However, 35 % of smokers and 27 % of vapers reported increasing smoking and vaping, respectively, during the pandemic. CONCLUSIONS Most patients with OUD believed that smoking and vaping increased their vulnerability to COVID-19, half reported increased interest in quitting, but others reported increasing smoking and vaping during the COVID-19 pandemic.
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Affiliation(s)
- Joanna M. Streck
- Tobacco Research and Treatment Center, Division of General Internal Medicine Department of Medicine, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA,Department of Psychiatry, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA,Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA,Corresponding author at: Tobacco Research and Treatment Center, Departments of Medicine and Psychiatry, Massachusetts General Hospital/Harvard Medical School, 100 Cambridge Street, Suite 1600, Boston, MA 02114, USA
| | - Sara Kalkhoran
- Tobacco Research and Treatment Center, Division of General Internal Medicine Department of Medicine, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA,Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Benjamin Bearnot
- Tobacco Research and Treatment Center, Division of General Internal Medicine Department of Medicine, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA,Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Priya S. Gupta
- Tobacco Research and Treatment Center, Division of General Internal Medicine Department of Medicine, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA,Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Kelly M. Kalagher
- Tobacco Research and Treatment Center, Division of General Internal Medicine Department of Medicine, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA
| | - Susan Regan
- Tobacco Research and Treatment Center, Division of General Internal Medicine Department of Medicine, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA,Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Sarah Wakeman
- Tobacco Research and Treatment Center, Division of General Internal Medicine Department of Medicine, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA,Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Nancy A. Rigotti
- Tobacco Research and Treatment Center, Division of General Internal Medicine Department of Medicine, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA,Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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13
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Kimmel SD, Rosenmoss S, Bearnot B, Larochelle M, Walley AY. Rejection of Patients With Opioid Use Disorder Referred for Post-acute Medical Care Before and After an Anti-discrimination Settlement in Massachusetts. J Addict Med 2021; 15:20-26. [PMID: 32675798 PMCID: PMC7859880 DOI: 10.1097/adm.0000000000000693] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [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: 11/25/2022]
Abstract
OBJECTIVES To determine how commonly medical inpatients with opioid use disorder (OUD) referred for postacute medical care were rejected due to substance use or treatment with opioid agonist therapy (OAT). Additionally, to assess for changes in rejection rates following the United States Attorney's May 2018 settlement with a Massachusetts nursing facility for violating anti-discrimination laws for such rejections. METHODS We linked electronic referrals to private Massachusetts postacute medical care facilities from Boston Medical Center in 2018 with clinical data. We included referrals with evidence of OUD using ICD-10 diagnosis codes or OAT receipt. We identified the frequency of referrals where the stated rejection reason was substance use or OAT and classified these as discriminatory. We used segmented regression to assess for changes in proportion of referrals with substance use and OAT-related rejections before and after the settlement. RESULTS In 2018, 219 OUD-associated hospitalizations resulted in 1648 referrals to 285 facilities; 81.8% (1348) were rejected. Among hospitalizations, 37.4% (82) received at least 1 discriminatory rejection. Among rejections, 15.1% (203) were discriminatory (105 for OAT and 98 for substance use). Among facilities, 29.1% (83) had at least one discriminatory rejection. We found no differences in proportion of discriminatory rejections before and after the settlement. CONCLUSIONS Individuals hospitalized with OUD frequently experience explicit discrimination when rejected from postacute care despite federal and state protections. Efforts are needed to enhance enforcement of anti-discrimination laws, regulations, and policies to ensure access to postacute medical care for people with OUD and ongoing medical needs.
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Affiliation(s)
- Simeon D Kimmel
- Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, MA (SDK, SR, MLR, AYW); The Grayken Center for Addiction, Boston Medical Center (SDK, MLR, AYW); Division of General Internal Medicine and Mongan Institute, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA (BB)
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14
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Vyas DA, Marinacci L, Sundt T, Jassar A, Bearnot B, Triant VA, Nelson SB, Wakeman SE, Dudzinski DM, Paras ML. 709. Multidisciplinary Drug Use Endocarditis Team (DUET): Results From an Academic Center Cohort. Open Forum Infect Dis 2020. [PMCID: PMC7776411 DOI: 10.1093/ofid/ofaa439.901] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background Guidelines recommend multidisciplinary models for the management of infective endocarditis but have failed to incorporate the unique challenges of treating drug-use associated infective endocarditis (DUA-IE). Given the drug use and overdose epidemic with rising cases of DUA-IE, we created a multidisciplinary Drug Use Endocarditis Team (DUET), which convened monthly case conferences among the specialties involved, including Infectious Diseases, Cardiothoracic Surgery, Cardiology and Addiction Medicine. Objective: To conduct a retrospective cohort study of the patients presented at the DUET conferences from August 2018 to February 2020 to (1) assess clinical and demographic characteristics and (2) describe clinical outcomes. Methods A retrospective chart review was conducted to analyze 57 patient cases, including descriptive statistical analyses of demographics, clinical characteristics, and outcomes. Results Among our DUET cohort, 43.8% represented isolated right-sided endocarditis, and 84% involved native valve. Methicillin-susceptible Staphylococcus aureus was the most common microorganism isolated. ID was consulted in 94.7% of cases and overall 43.9% completed the planned antimicrobial course. The 7 patients who developed relapse/recurrent IE were initially managed medically, and 5 did not complete the initial antimicrobial course. Formal cardiothoracic surgery consultation was obtained in 57.9% and 24.6% were managed operatively. Of the patients managed operatively, 64.3% completed the antimicrobial course. The rate of antibiotic completion was higher among patients managed operatively but did not reach statistical significance (p=0.08). Formal addiction medicine consultation was obtained in 85.9% of cases, with 63.1% discharged on medications for opioid use disorder (MOUD). The rate of MOUD on discharge was not significantly different between patients managed operatively and non-operatively. Figure 1: Patient Characteristics ![]()
Figure 2: Infection Characteristics ![]()
Figure 3: Outcome Analyses ![]()
Conclusion ID is nearly universally involved in the care of patients with DUA-IE, but this patient population requires input from numerous sub-specialties. Multidisciplinary care teams provide a promising framework for DUA-IE to enhance and integrate nuanced decision-making. Disclosures Sarah E. Wakeman, MD, Celero Systems (Advisor or Review Panel member)Optum Labs (Grant/Research Support)UpToDate (Other Financial or Material Support, Author)
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Affiliation(s)
| | | | - Thoralf Sundt
- Massachusetts General Hospital, Cambridge, Massachusetts
| | - Arminder Jassar
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | | | | | | | | | | | - Molly L Paras
- Massachusetts General Hospital, Cambridge, Massachusetts
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15
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Bearnot B, Mitton JA. "You're Always Jumping Through Hoops": Journey Mapping the Care Experiences of Individuals With Opioid Use Disorder-associated Endocarditis. J Addict Med 2020; 14:494-501. [PMID: 32142056 PMCID: PMC7483139 DOI: 10.1097/adm.0000000000000648] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [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: 12/24/2022]
Abstract
OBJECTIVES Serious infectious complications of opioid use disorder (OUD), and specifically endocarditis, are becoming more common in the US. Individuals with OUD-associated endocarditis require long periods of complex medical care, often face recurrent addiction- and infection-related complications, and have dismal clinical outcomes. The objective of this study was to perform journey mapping analysis to capture common trajectories and patterns of care for people with OUD-associated endocarditis. METHODS This was an analysis of qualitative semi-structured interviews of individuals who received care for OUD-associated endocarditis. Interviews were conducted among individuals receiving care at a single academic healthcare system in Boston, Massachusetts. Ten participants meeting DSM-5 criteria for at least mild OUD and a culture-positive diagnosis of endocarditis who had previously completed care for OUD-associated endocarditis were recruited from inpatient and ambulatory settings. Details of participant's care episodes were extracted and visualized in an iterative journey mapping process. A grounded theory approach was then used to identify shared themes and care patterns among participants' journey maps. RESULTS Common patterns of care included early addiction treatment and intensive outpatient care preceding periods without rehospitalization, while leaving outpatient care and return to drug use often directly preceded rehospitalization. Participants frequently left care by choice and proactively reengaged with care. CONCLUSIONS Journey mapping is a novel, patient-centered approach to capturing the care experiences and trajectories of a patient population experiencing significant stigma, who engage with the healthcare system in unexpected and fragmented ways. For individuals with OUD-associated endocarditis, we identified critical moments to support and engage patients to prevent return to drug use and rehospitalization.
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Affiliation(s)
- Benjamin Bearnot
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts
| | - Julian A. Mitton
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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16
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Fozouni L, Khan S, Bearnot B. Spatiotemporal Trends in Discarded Needle Reports in San Francisco Over a 10-year Period, 2010-2019. Int J Drug Policy 2020; 87:103018. [PMID: 33142160 DOI: 10.1016/j.drugpo.2020.103018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 06/15/2020] [Revised: 10/19/2020] [Accepted: 10/24/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND To describe the geographic and spatiotemporal distribution of needle reports in San Francisco, and examine spatial relationships between needle reports and needle disposal boxes, needle disposal kiosks, and homeless shelters. METHODS We conducted multiple geospatial analyses of a crowdsourced database of non-emergency service requests. We describe changes in discarded needle and bulky item reports across San Francisco between 2010 and 2019, and compared changes in the reporting patterns of these items, while 200-meter Euclidean buffers captured needle reports in close proximity to needle deposit boxes, needle deposit kiosks, and homeless shelters in 2019. RESULTS 34,912 needle reports were included. Yearly needle reports increased by 3827.1%, with a markedly different geospatial distribution from bulky item reports. 45.6% of needle reports originated in the five downtown neighborhoods with the highest needle report density, and 33.8% were identified within 200 meters of boxes, kiosks, or homeless shelters. CONCLUSIONS Reports of discarded needles in San Francisco increased dramatically over the last decade, and more than one third of 2019 reports were adjacent to harm reduction and homeless shelter locations. Needle reports provide an opportunity to understand changes in public injection drug use and target harm reduction services.
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Affiliation(s)
- Laila Fozouni
- University of California San Francisco School of Medicine, 533 Parnassus Ave, San Francisco, California, 94143 USA
| | - Saira Khan
- Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, Massachusetts, 02115 USA
| | - Benjamin Bearnot
- Division of General Internal Medicine and Mongan Institute, Massachusetts General Hospital, 55 Fruit St, Boston, Massachusetts, 02114 USA; Department of Medicine, Harvard Medical School, 25 Shattuck St, Boston, Massachusetts, 02115 USA.
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17
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Bearnot B, Fine DR, Rigotti NA, Baggett TP. Access to Treatment for Drug Use Disorders at US Health Centers: a National Study. J Gen Intern Med 2019; 34:2723-2725. [PMID: 31090029 PMCID: PMC6854200 DOI: 10.1007/s11606-019-05043-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 04/16/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Benjamin Bearnot
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA. .,Department of Medicine, Harvard Medical School, Boston, MA, USA.
| | - Danielle R Fine
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Nancy A Rigotti
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA.,Tobacco Research and Treatment Center, Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Travis P Baggett
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA.,Institute for Research, Quality, and Policy in Homeless Health Care, Boston Health Care for the Homeless Program, Boston, MA, USA
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18
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Bearnot B, Mitton JA, Hayden M, Park ER. Experiences of care among individuals with opioid use disorder-associated endocarditis and their healthcare providers: Results from a qualitative study. J Subst Abuse Treat 2019; 102:16-22. [DOI: 10.1016/j.jsat.2019.04.008] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 04/18/2019] [Accepted: 04/19/2019] [Indexed: 01/04/2023]
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19
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Myran DT, Chen JT, Bearnot B, Ip M, Giesbrecht N, Rees VW. Alcohol Availability Across Neighborhoods in Ontario Following Alcohol Sales Deregulation, 2013-2017. Am J Public Health 2019; 109:899-905. [PMID: 30998409 DOI: 10.2105/ajph.2019.305014] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Objectives. To examine the association between neighborhood socioeconomic status (SES) and alcohol availability before and after deregulation in 2015 of the alcohol market in Ontario, Canada. Methods. We quantified alcohol access by number of alcohol outlets and hours of retail for all 19 964 neighborhoods in Ontario. We used mixed effects regression models to examine the associations between alcohol access and a validated SES index between 2013 and 2017. Results. Following deregulation, the number of alcohol outlets in Ontario increased by 15.0%. Low neighborhood SES was positively associated with increased alcohol access: lower-SES neighborhoods had more alcohol outlets within 1000 meters and were closer to the nearest alcohol outlets. Outlets located in low-SES neighborhoods kept longer hours of operation. Conclusions. We observed a substantial increase in alcohol access in Ontario following deregulation. Access to alcohol was greatest in low-SES neighborhoods and may contribute to established inequities in alcohol harms. Public Health Implications. Placing limits on number of alcohol outlets and the hours of operation in low-SES neighborhoods offers an opportunity to reduce alcohol-related health inequities.
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Affiliation(s)
- Daniel T Myran
- Daniel T. Myran is with the School of Epidemiology and Public Health, University of Ottawa, Faculty of Medicine, Ottawa, ON. Jarvis T. Chen and Vaughan W. Rees are with the Department of Social and Behavioral Sciences, Harvard T. H. Chan School of Public Health, Boston, MA. Benjamin Bearnot is with the Division of General Internal Medicine, Massachusetts General Hospital, Boston. Michael Ip is with the School of Epidemiology and Public Health, University of Ottawa, Faculty of Medicine. Norman Giesbrecht is with the Institute for Mental Health Policy Research, Center for Addiction and Mental Health, Toronto, ON
| | - Jarvis T Chen
- Daniel T. Myran is with the School of Epidemiology and Public Health, University of Ottawa, Faculty of Medicine, Ottawa, ON. Jarvis T. Chen and Vaughan W. Rees are with the Department of Social and Behavioral Sciences, Harvard T. H. Chan School of Public Health, Boston, MA. Benjamin Bearnot is with the Division of General Internal Medicine, Massachusetts General Hospital, Boston. Michael Ip is with the School of Epidemiology and Public Health, University of Ottawa, Faculty of Medicine. Norman Giesbrecht is with the Institute for Mental Health Policy Research, Center for Addiction and Mental Health, Toronto, ON
| | - Benjamin Bearnot
- Daniel T. Myran is with the School of Epidemiology and Public Health, University of Ottawa, Faculty of Medicine, Ottawa, ON. Jarvis T. Chen and Vaughan W. Rees are with the Department of Social and Behavioral Sciences, Harvard T. H. Chan School of Public Health, Boston, MA. Benjamin Bearnot is with the Division of General Internal Medicine, Massachusetts General Hospital, Boston. Michael Ip is with the School of Epidemiology and Public Health, University of Ottawa, Faculty of Medicine. Norman Giesbrecht is with the Institute for Mental Health Policy Research, Center for Addiction and Mental Health, Toronto, ON
| | - Michael Ip
- Daniel T. Myran is with the School of Epidemiology and Public Health, University of Ottawa, Faculty of Medicine, Ottawa, ON. Jarvis T. Chen and Vaughan W. Rees are with the Department of Social and Behavioral Sciences, Harvard T. H. Chan School of Public Health, Boston, MA. Benjamin Bearnot is with the Division of General Internal Medicine, Massachusetts General Hospital, Boston. Michael Ip is with the School of Epidemiology and Public Health, University of Ottawa, Faculty of Medicine. Norman Giesbrecht is with the Institute for Mental Health Policy Research, Center for Addiction and Mental Health, Toronto, ON
| | - Norman Giesbrecht
- Daniel T. Myran is with the School of Epidemiology and Public Health, University of Ottawa, Faculty of Medicine, Ottawa, ON. Jarvis T. Chen and Vaughan W. Rees are with the Department of Social and Behavioral Sciences, Harvard T. H. Chan School of Public Health, Boston, MA. Benjamin Bearnot is with the Division of General Internal Medicine, Massachusetts General Hospital, Boston. Michael Ip is with the School of Epidemiology and Public Health, University of Ottawa, Faculty of Medicine. Norman Giesbrecht is with the Institute for Mental Health Policy Research, Center for Addiction and Mental Health, Toronto, ON
| | - Vaughan W Rees
- Daniel T. Myran is with the School of Epidemiology and Public Health, University of Ottawa, Faculty of Medicine, Ottawa, ON. Jarvis T. Chen and Vaughan W. Rees are with the Department of Social and Behavioral Sciences, Harvard T. H. Chan School of Public Health, Boston, MA. Benjamin Bearnot is with the Division of General Internal Medicine, Massachusetts General Hospital, Boston. Michael Ip is with the School of Epidemiology and Public Health, University of Ottawa, Faculty of Medicine. Norman Giesbrecht is with the Institute for Mental Health Policy Research, Center for Addiction and Mental Health, Toronto, ON
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Affiliation(s)
- Benjamin Bearnot
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA. .,Department of Medicine, Harvard Medical School, Boston, MA, USA.
| | - Nancy A Rigotti
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA.,Tobacco Research and Treatment Center, Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Travis P Baggett
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA.,Institute for Research, Quality, and Policy in Homeless Health Care, Boston Health Care for the Homeless Program, Boston, MA, USA
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21
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Bearnot B, Pearson JF, Rodriguez JA. Using Publicly Available Data to Understand the Opioid Overdose Epidemic: Geospatial Distribution of Discarded Needles in Boston, Massachusetts. Am J Public Health 2018; 108:1355-1357. [PMID: 30138067 DOI: 10.2105/ajph.2018.304583] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To use publicly available, crowdsourced data to understand geospatial trends in discarded needles. METHODS We completed multiple geospatial analyses of discarded needles reported through the Boston, Massachusetts, 311 service request system. RESULTS Between May 2015 and August 2017, 4763 discarded needles were reported. The highest concentration of needles were reported in census block groups in the South End and Roxbury neighborhoods. Cumulatively, 78.3% of the needles were reported within 1 kilometer of methadone clinics, safe needle deposit sites, homeless shelters, or hospitals. CONCLUSIONS Publicly reported data can help identify hot spots of discarded needles and examine indicators of spatial association. In Boston, the number of discarded needles being reported is rising, with the highest density of needles found in 2 central neighborhoods with several outlying hot spots. Most needles were found near areas associated with social stress and substance use disorder. Public Health Implications. This analysis represents a novel way of leveraging publicly available information to target community responses to the opioid epidemic. Identifying hot spots of discarded needles may enable public health organizations to target future efforts to encourage safer needle disposal practices and reduce public injection drug use.
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Affiliation(s)
- Benjamin Bearnot
- Benjamin Bearnot is with the Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, and Department of Medicine, Harvard Medical School, Boston. John F. Pearson and Jorge A. Rodriguez are with the Division of Clinical Informatics, Beth Israel Deaconess Medical Center, Boston. John F. Pearson is also with the Department of Anesthesiology, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center
| | - John F Pearson
- Benjamin Bearnot is with the Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, and Department of Medicine, Harvard Medical School, Boston. John F. Pearson and Jorge A. Rodriguez are with the Division of Clinical Informatics, Beth Israel Deaconess Medical Center, Boston. John F. Pearson is also with the Department of Anesthesiology, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center
| | - Jorge A Rodriguez
- Benjamin Bearnot is with the Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, and Department of Medicine, Harvard Medical School, Boston. John F. Pearson and Jorge A. Rodriguez are with the Division of Clinical Informatics, Beth Israel Deaconess Medical Center, Boston. John F. Pearson is also with the Department of Anesthesiology, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center
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Ankomah P, Mccluskey S, Abers M, Bearnot B, Patel S, Schuetz P, Chiappa V, Lewandrowski K, Vyas J, Mansour M. Serial Procalcitonin Levels Correlate with Microbial Etiology in Hospitalized Patients with Pneumonia. Open Forum Infect Dis 2017. [PMCID: PMC5631196 DOI: 10.1093/ofid/ofx163.846] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background Procalcitonin (PCT) is a biomarker that is finding increasing diagnostic and prognostic utility in lower respiratory infections. It remains unclear, however, whether it can be helpful in predicting the bacterial etiology of pneumonia, with a view to informing antibiotic choice and duration. This study examines the relationship between serial PCT measurements and microbial etiology in patients hospitalized for pneumonia to determine whether changes in PCT levels provide discriminatory information on microbial etiology. Methods We performed a subgroup analysis of data from a prospective cohort study of 505 patients admitted to a tertiary care center with findings concerning for pneumonia. Microbial etiology of pneumonia was determined from high quality respiratory samples, blood cultures or other relevant diagnostic tests according to standard protocols. Procalcitonin levels were measured serially during the first four days of hospitalization. We compared procalcitonin levels between different bacterial etiologies over the first four days of admission, using the Mann–Whitney-U test to assess for statistical significance. Results Out of 505 patients, the diagnosis of pneumonia was adjudicated in 317, and bacterial etiology determined in 62 cases. The predominant pathogens were Staphylococcus aureus (N = 18), Streptococcus pneumoniae (N = 6), Pseudomonas aeruginosa (N = 11) and Haemophilus influenza (N = 5). Admission levels of PCT were lowest in Pseudomonas infections and highest in pneumococcal infections, though not reaching statistical significance. On hospital days two and three, pneumococcal procalcitonin levels were significantly higher than all other etiologies, but on day four, there was no statistically significant difference in PCT values for different microbial etiologies. Conclusion Serial procalcitonin levels during the early course of bacterial pneumonia reveal a difference between pneumococcal and other bacterial etiologies, and may have an adjunct role in guiding antibiotic choice and duration. Disclosures All authors: No reported disclosures.
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Affiliation(s)
| | - Suzanne Mccluskey
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Michael Abers
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Benjamin Bearnot
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Philipp Schuetz
- Medical University Clinic, Kantonsspital Aarau, Aarau, Switzerland
| | - Victor Chiappa
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Kent Lewandrowski
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts
| | - Jatin Vyas
- Medicine; Infectious Disease, Massachusetts General Hospital, Boston, Massachusetts
| | - Michael Mansour
- Massachusetts General Hospital, Division of Infectious Diseases, Boston, Massachusetts
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Dworkis DA, Taylor LA, Peak DA, Bearnot B. Geospatial analysis of emergency department visits for targeting community-based responses to the opioid epidemic. PLoS One 2017; 12:e0175115. [PMID: 28362828 PMCID: PMC5376332 DOI: 10.1371/journal.pone.0175115] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [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: 11/07/2016] [Accepted: 03/21/2017] [Indexed: 12/02/2022] Open
Abstract
The opioid epidemic in the United States carries significant morbidity and mortality and requires a coordinated response among emergency providers, outpatient providers, public health departments, and communities. Anecdotally, providers across the spectrum of care at Massachusetts General Hospital (MGH) in Boston, MA have noticed that Charlestown, a community in northeast Boston, has been particularly impacted by the opioid epidemic and needs both emergency and longer-term resources. We hypothesized that geospatial analysis of the home addresses of patients presenting to the MGH emergency department (ED) with opioid-related emergencies might identify “hot spots” of opioid-related healthcare needs within Charlestown that could then be targeted for further investigation and resource deployment. Here, we present a geospatial analysis at the United States census tract level of the home addresses of all patients who presented to the MGH ED for opioid-related emergency visits between 7/1/2012 and 6/30/2015, including 191 visits from 100 addresses in Charlestown, MA. Among the six census tracts that comprise Charlestown, we find a 9.5-fold difference in opioid-related ED visits, with 45% of all opioid-related visits from Charlestown originating in tract 040401. The signal from this census tract remains strong after adjusting for population differences between census tracts, and while this tract is one of the higher utilizing census tracts in Charlestown of the MGH ED for all cause visits, it also has a 2.9-fold higher rate of opioid-related visits than the remainder of Charlestown. Identifying this hot spot of opioid-related emergency needs within Charlestown may help re-distribute existing resources efficiently, empower community and ED-based physicians to advocate for their patients, and serve as a catalyst for partnerships between MGH and local community groups. More broadly, this analysis demonstrates that EDs can use geospatial analysis to address the emergency and longer-term health needs of the communities they are designed to serve.
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Affiliation(s)
- Daniel A. Dworkis
- Harvard Medical School, Department of Emergency Medicine, Boston, Massachusetts, United States of America
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts, United States of America
- * E-mail:
| | - Lauren A. Taylor
- Harvard Management Business School, Boston, Massachusetts, United States of America
| | - David A. Peak
- Harvard Medical School, Department of Emergency Medicine, Boston, Massachusetts, United States of America
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts, United States of America
| | - Benjamin Bearnot
- Harvard Medical School, Department of Medicine, Boston, Massachusetts, United States of America
- Massachusetts General Hospital, Division of General Internal Medicine, Department of Medicine, Boston, Massachusetts, United States of America
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McCluskey SM, Schuetz P, Abers MS, Bearnot B, Morales ME, Hoffman D, Patel S, Rosario L, Chiappa V, Parry BA, Callahan RT, Bond SA, Lewandrowski K, Binder W, Filbin MR, Vyas JM, Mansour MK. Serial Procalcitonin as a Predictor of Bacteremia and Need for Intensive Care Unit Care in Adults With Pneumonia, Including Those With Highest Severity: A Prospective Cohort Study. Open Forum Infect Dis 2017; 4:ofw238. [PMID: 28480236 PMCID: PMC5414101 DOI: 10.1093/ofid/ofw238] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 10/24/2016] [Accepted: 12/21/2016] [Indexed: 01/09/2023] Open
Abstract
Background Procalcitonin (PCT) is a prohormone that rises in bacterial pneumonia and has promise in reducing antibiotic use. Despite these attributes, there are inconclusive data on its use for clinical prognostication. We hypothesize that serial PCT measurements can predict mortality, intensive care unit (ICU) admission, and bacteremia. Methods A prospective cohort study of inpatients diagnosed with pneumonia was performed at a large tertiary care center in Boston, Massachusetts. Procalcitonin was measured on days 1 through 4. The primary endpoint was a composite adverse outcome defined as all-cause mortality, ICU admission, and bacteremia. Regression models were calculated with area under the receiver operating characteristic curve (AUC) as a measure of discrimination. Results Of 505 patients, 317 patients had a final diagnosis of community-acquired pneumonia (CAP) or healthcare-associated pneumonia (HCAP). Procalcitonin was significantly higher for CAP and HCAP patients meeting the composite primary endpoint, bacteremia, and ICU admission, but not mortality. Incorporation of serial PCT levels into a statistical model including the Pneumonia Severity Index (PSI) improved the prognostic performance of the PSI with respect to the primary composite endpoint (AUC from 0.61 to 0.66), bacteremia (AUC from 0.67 to 0.85), and need for ICU-level care (AUC from 0.58 to 0.64). For patients in the highest risk class PSI >130, PCT was capable of further risk stratification for prediction of adverse outcomes. Conclusion Serial PCT measurement in patients with pneumonia shows promise for predicting adverse clinical outcomes, including in those at highest mortality risk.
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Affiliation(s)
- Suzanne M McCluskey
- Department of Medicine, Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts
| | - Philipp Schuetz
- University of Basel, Kantonsspital Aarau, Switzerland; Departments of
| | | | | | | | | | | | - Lauren Rosario
- Department of Medicine, Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts
| | | | | | | | - Sheila A Bond
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts
| | | | - William Binder
- Alpert School of Medicine, Brown University, Rhode Island and Miriam Hospitals, Providence, Rhode Island
| | | | - Jatin M Vyas
- Department of Medicine, Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts
| | - Michael K Mansour
- Department of Medicine, Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts
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Mccluskey S, Abers M, Bearnot B, Hoffman D, Morales M, Patel S, Rosario L, Schuetz P, Parry B, Callahan R, Chiappa V, Lewandrowski K, Binder W, Filbin M, Vyas J, Mansour M. Serial Procalcitonin Measurements for Improved Prognostic Assessment of Patients Admitted with Bacterial Pneumonia. Open Forum Infect Dis 2015. [DOI: 10.1093/ofid/ofv133.121] [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: 11/12/2022] Open
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26
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Bassett IV, Regan S, Mbonambi H, Blossom J, Bogan S, Bearnot B, Robine M, Walensky RP, Mhlongo B, Freedberg KA, Thulare H, Losina E. Finding HIV in hard to reach populations: mobile HIV testing and geospatial mapping in Umlazi township, Durban, South Africa. AIDS Behav 2015; 19:1888-95. [PMID: 25874754 PMCID: PMC4531102 DOI: 10.1007/s10461-015-1012-3] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [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: 11/30/2022]
Abstract
Mobile, community-based HIV testing may help achieve universal HIV testing in South Africa. We compared the yield, geographic distribution, and demographic characteristics of populations tested by mobile- and clinic-based HIV testing programs deployed by iThembalabantu Clinic in Durban, South Africa. From July to November 2011, 4,701 subjects were tested; HIV prevalence was 35 % among IPHC testers and 10 % among mobile testers (p < 0.001). Mobile testers varied in mean age (22-37 years) and % males (26-67 %). HIV prevalence at mobile sites ranged from 0 to 26 %. Testers traveled further than the clinic closest to their home; mobile testers were more likely to test ≥5 km away from home. Mobile HIV testing can improve testing access and identify testing sites with high HIV prevalence. Individuals often access mobile testing sites farther from home than their nearest clinic. Geospatial techniques can help optimize deployment of mobile units to maximize yield in hard-to-reach populations.
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Affiliation(s)
- Ingrid V Bassett
- Medical Practice Evaluation Center, Massachusetts General Hospital, 50 Staniford Street, Floor 9, Boston, MA, 02114, USA.
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA.
- Harvard Center for AIDS Research, Harvard University, Boston, MA, USA.
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.
| | - Susan Regan
- Medical Practice Evaluation Center, Massachusetts General Hospital, 50 Staniford Street, Floor 9, Boston, MA, 02114, USA
| | - Hlengiwe Mbonambi
- iThembalabantu People's Hope Clinic/AIDS Healthcare Foundation, Durban, South Africa
| | | | - Stacy Bogan
- Harvard Center for Geographic Analysis, Cambridge, MA, USA
| | - Benjamin Bearnot
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Marion Robine
- Medical Practice Evaluation Center, Massachusetts General Hospital, 50 Staniford Street, Floor 9, Boston, MA, 02114, USA
| | - Rochelle P Walensky
- Medical Practice Evaluation Center, Massachusetts General Hospital, 50 Staniford Street, Floor 9, Boston, MA, 02114, USA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
- Harvard Center for AIDS Research, Harvard University, Boston, MA, USA
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA, USA
| | - Bright Mhlongo
- iThembalabantu People's Hope Clinic/AIDS Healthcare Foundation, Durban, South Africa
| | - Kenneth A Freedberg
- Medical Practice Evaluation Center, Massachusetts General Hospital, 50 Staniford Street, Floor 9, Boston, MA, 02114, USA
- Harvard Center for AIDS Research, Harvard University, Boston, MA, USA
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Hilary Thulare
- iThembalabantu People's Hope Clinic/AIDS Healthcare Foundation, Durban, South Africa
| | - Elena Losina
- Medical Practice Evaluation Center, Massachusetts General Hospital, 50 Staniford Street, Floor 9, Boston, MA, 02114, USA
- Harvard Center for AIDS Research, Harvard University, Boston, MA, USA
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
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27
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Abdool Karim Q, Dellar RC, Bearnot B, Werner L, Frohlich JA, Kharsany ABM, Abdool Karim SS. HIV-positive status disclosure in patients in care in rural South Africa: implications for scaling up treatment and prevention interventions. AIDS Behav 2015; 19:322-9. [PMID: 25677128 PMCID: PMC4345171 DOI: 10.1007/s10461-014-0951-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [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: 10/24/2022]
Abstract
A nuanced understanding of HIV-positive status disclosure is urgently needed to inform the implementation of prevention interventions, including TasP and PrEP. To provide such understanding for the high HIV-burden setting of rural KwaZulu-Natal, we conducted a prospective cohort study to characterize determinants and trends in HIV-positive status disclosure. 687 consenting HIV-positive individuals (73.2 % female; 60.3 % ART initiated) were enrolled. Reports of any incidence of disclosure to either a family member or sexual partner at enrollment and follow-up visits (median 4.4 months post-enrolment) were common (91.0 %); however, reports of disclosure specifically to sexual partners were relatively rare (34.1 %), especially in women (29.8 %). Participants not engaged in a stable partnerships, not ART-imitated, and/or who had disclosed to their family were at risk of non-disclosure to sexual partners. These data highlight both an urgent need to empower HIV-positive individuals, and the significant barriers to targeting sero-discordant couples for HIV prevention in this setting.
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Affiliation(s)
- Quarraisha Abdool Karim
- Centre for AIDS Programme of Research in South Africa (CAPRISA), Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
- Mailman School of Public Health, Department of Epidemiology, Columbia University, New York, USA
| | - Rachael C Dellar
- Centre for AIDS Programme of Research in South Africa (CAPRISA), Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | | | - Lise Werner
- Mailman School of Public Health, Department of Epidemiology, Columbia University, New York, USA
| | - Janet A Frohlich
- Mailman School of Public Health, Department of Epidemiology, Columbia University, New York, USA
| | - Ayesha BM Kharsany
- Mailman School of Public Health, Department of Epidemiology, Columbia University, New York, USA
| | - Salim S Abdool Karim
- Centre for AIDS Programme of Research in South Africa (CAPRISA), Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
- Mailman School of Public Health, Department of Epidemiology, Columbia University, New York, USA
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Bearnot B, Coria A, Barnett BS, Clark EH, Gartland MG, Jaganath D, Mendenhall E, Seu L, Worjoloh AG, Carothers CL, Vermund SH, Heimburger DC. Global health research in narrative: a qualitative look at the FICRS-F experience. Am J Trop Med Hyg 2014; 91:863-8. [PMID: 25246694 DOI: 10.4269/ajtmh.13-0481] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
For American professional and graduate health sciences trainees, a mentored fellowship in a low- or middle-income country (LMIC) can be a transformative experience of personal growth and scientific discovery. We invited 86 American trainees in the Fogarty International Clinical Research Scholars and Fellows Program and Fulbright-Fogarty Fellowship 2011-2012 cohorts to contribute personal essays about formative experiences from their fellowships. Nine trainees contributed essays that were analyzed using an inductive approach. The most frequently addressed themes were the strong continuity of research and infrastructure at Fogarty fellowship sites, the time-limited nature of this international fellowship experience, and the ways in which this fellowship period was important for shaping future career planning. Trainees also addressed interaction with host communities vis-à-vis engagement in project implementation. These qualitative essays have contributed insights on how a 1-year mentored LMIC-based research training experience can influence professional development, complementing conventional evaluations. Full text of the essays is available at http://fogartyscholars.org/.
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Affiliation(s)
- Benjamin Bearnot
- New York University School of Medicine, New York, New York; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; Vanderbilt University School of Medicine, Nashville, Tennessee; Vanderbilt Institute for Global Health, Nashville, Tennessee; University of Alabama at Birmingham, Birmingham, Alabama; University of California at Los Angeles, Los Angeles, California; Georgetown University, Washington, District of Columbia; Duke University Medical Center, Durham, North Carolina
| | - Alexandra Coria
- New York University School of Medicine, New York, New York; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; Vanderbilt University School of Medicine, Nashville, Tennessee; Vanderbilt Institute for Global Health, Nashville, Tennessee; University of Alabama at Birmingham, Birmingham, Alabama; University of California at Los Angeles, Los Angeles, California; Georgetown University, Washington, District of Columbia; Duke University Medical Center, Durham, North Carolina
| | - Brian Scott Barnett
- New York University School of Medicine, New York, New York; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; Vanderbilt University School of Medicine, Nashville, Tennessee; Vanderbilt Institute for Global Health, Nashville, Tennessee; University of Alabama at Birmingham, Birmingham, Alabama; University of California at Los Angeles, Los Angeles, California; Georgetown University, Washington, District of Columbia; Duke University Medical Center, Durham, North Carolina
| | - Eva H Clark
- New York University School of Medicine, New York, New York; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; Vanderbilt University School of Medicine, Nashville, Tennessee; Vanderbilt Institute for Global Health, Nashville, Tennessee; University of Alabama at Birmingham, Birmingham, Alabama; University of California at Los Angeles, Los Angeles, California; Georgetown University, Washington, District of Columbia; Duke University Medical Center, Durham, North Carolina
| | - Matthew G Gartland
- New York University School of Medicine, New York, New York; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; Vanderbilt University School of Medicine, Nashville, Tennessee; Vanderbilt Institute for Global Health, Nashville, Tennessee; University of Alabama at Birmingham, Birmingham, Alabama; University of California at Los Angeles, Los Angeles, California; Georgetown University, Washington, District of Columbia; Duke University Medical Center, Durham, North Carolina
| | - Devan Jaganath
- New York University School of Medicine, New York, New York; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; Vanderbilt University School of Medicine, Nashville, Tennessee; Vanderbilt Institute for Global Health, Nashville, Tennessee; University of Alabama at Birmingham, Birmingham, Alabama; University of California at Los Angeles, Los Angeles, California; Georgetown University, Washington, District of Columbia; Duke University Medical Center, Durham, North Carolina
| | - Emily Mendenhall
- New York University School of Medicine, New York, New York; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; Vanderbilt University School of Medicine, Nashville, Tennessee; Vanderbilt Institute for Global Health, Nashville, Tennessee; University of Alabama at Birmingham, Birmingham, Alabama; University of California at Los Angeles, Los Angeles, California; Georgetown University, Washington, District of Columbia; Duke University Medical Center, Durham, North Carolina
| | - Lillian Seu
- New York University School of Medicine, New York, New York; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; Vanderbilt University School of Medicine, Nashville, Tennessee; Vanderbilt Institute for Global Health, Nashville, Tennessee; University of Alabama at Birmingham, Birmingham, Alabama; University of California at Los Angeles, Los Angeles, California; Georgetown University, Washington, District of Columbia; Duke University Medical Center, Durham, North Carolina
| | - Ayaba G Worjoloh
- New York University School of Medicine, New York, New York; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; Vanderbilt University School of Medicine, Nashville, Tennessee; Vanderbilt Institute for Global Health, Nashville, Tennessee; University of Alabama at Birmingham, Birmingham, Alabama; University of California at Los Angeles, Los Angeles, California; Georgetown University, Washington, District of Columbia; Duke University Medical Center, Durham, North Carolina
| | - Catherine Lem Carothers
- New York University School of Medicine, New York, New York; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; Vanderbilt University School of Medicine, Nashville, Tennessee; Vanderbilt Institute for Global Health, Nashville, Tennessee; University of Alabama at Birmingham, Birmingham, Alabama; University of California at Los Angeles, Los Angeles, California; Georgetown University, Washington, District of Columbia; Duke University Medical Center, Durham, North Carolina
| | - Sten H Vermund
- New York University School of Medicine, New York, New York; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; Vanderbilt University School of Medicine, Nashville, Tennessee; Vanderbilt Institute for Global Health, Nashville, Tennessee; University of Alabama at Birmingham, Birmingham, Alabama; University of California at Los Angeles, Los Angeles, California; Georgetown University, Washington, District of Columbia; Duke University Medical Center, Durham, North Carolina
| | - Douglas C Heimburger
- New York University School of Medicine, New York, New York; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; Vanderbilt University School of Medicine, Nashville, Tennessee; Vanderbilt Institute for Global Health, Nashville, Tennessee; University of Alabama at Birmingham, Birmingham, Alabama; University of California at Los Angeles, Los Angeles, California; Georgetown University, Washington, District of Columbia; Duke University Medical Center, Durham, North Carolina
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Bassett IV, Regan S, Luthuli P, Mbonambi H, Bearnot B, Pendleton A, Robine M, Mukuvisi D, Thulare H, Walensky RP, Freedberg KA, Losina E, Mhlongo B. Linkage to care following community-based mobile HIV testing compared with clinic-based testing in Umlazi Township, Durban, South Africa. HIV Med 2013; 15:367-72. [PMID: 24251725 DOI: 10.1111/hiv.12115] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2013] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The aim of the study was to assess HIV prevalence, disease stage and linkage to HIV care following diagnosis at a mobile HIV testing unit, compared with results for clinic-based testing, in a Durban township. METHODS This was a prospective cohort study. We enrolled adults presenting for HIV testing at a community-based mobile testing unit (mobile testers) and at an HIV clinic (clinic testers) serving the same area. Testers diagnosed with HIV infection, regardless of testing site, were offered immediate CD4 testing and instructed to retrieve results at the clinic. We assessed rates of linkage to care, defined as CD4 result retrieval within 90 days of HIV diagnosis and/or completion of antiretroviral therapy (ART) literacy training, for mobile vs. clinic testers. RESULTS From July to November 2011, 6957 subjects were HIV tested (4703 mobile and 2254 clinic); 55% were female. Mobile testers had a lower HIV prevalence than clinic testers (10% vs. 36%, respectively), were younger (median 23 vs. 27 years, respectively) and were more likely to live >5 km or >30 min from the clinic (64% vs. 40%, respectively; all P < 0.001). Mobile testers were less likely to undergo CD4 testing (33% vs. 83%, respectively) but more likely to have higher CD4 counts [median (interquartile range) 416 (287-587) cells/μL vs. 285 (136-482) cells/μL, respectively] than clinic testers (both P < 0.001). Of those who tested HIV positive, 10% of mobile testers linked to care, vs. 72% of clinic testers (P < 0.001). CONCLUSIONS Mobile HIV testing reaches people who are younger, who are more geographically remote, and who have earlier disease compared with clinic-based testing. Fewer mobile testers underwent CD4 testing and linked to HIV care. Enhancing linkage efforts may improve the impact of mobile testing for those with early HIV disease.
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Affiliation(s)
- I V Bassett
- Division of General Medicine, Massachusetts General Hospital, Boston, MA, USA; Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA; Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Harvard Center for AIDS Research, Harvard University, Boston, MA, USA
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Bassett IV, Wang B, Chetty S, Giddy J, Losina E, Mazibuko M, Bearnot B, Allen J, Walensky RP, Freedberg KA. Intensive tuberculosis screening for HIV-infected patients starting antiretroviral therapy in Durban, South Africa. Clin Infect Dis 2010; 51:823-9. [PMID: 20735240 DOI: 10.1086/656282] [Citation(s) in RCA: 109] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND The World Health Organization (WHO) recommends cough as the trigger for tuberculosis screening in human immunodeficiency virus (HIV)-infected patients, with acid-fast bacillus (AFB) smear as the initial diagnostic test. Our objective was to assess the yield and cost of a more intensive tuberculosis screening in HIV-infected patients starting antiretroviral therapy (ART) in Durban, South Africa. METHODS We prospectively enrolled adults, regardless of tuberculosis signs/symptoms, who were undergoing ART training from May 2007 to May 2008. After the symptom screen, patients expectorated sputum for AFB smear, tuberculosis polymerase chain reaction (PCR), and mycobacterial culture. Sensitivity and specificity of different symptoms and tests, alone and in combination, were compared with the reference standard of 6-week tuberculosis culture results. Program costs included personnel, materials, and cultures. RESULTS Of 1035 subjects, 487 (59%) were female; median CD4 cell count was 100 cells/microL. A total of 210 subjects (20%) were receiving tuberculosis treatment and were excluded. Of the remaining 825 subjects, 158 (19%) had positive sputum cultures, of whom 14 (9%) had a positive AFB smear and 82 (52%) reported cough. The combination of cough, other symptoms, AFB smear, and chest radiograph had 93% sensitivity (95% confidence interval, 88%-97%) and 15% specificity (95% confidence interval, 13%-18%). The incremental cost of intensive screening including culture was $360 per additional tuberculosis case identified. CONCLUSIONS Nearly 20% of patients starting ART in Durban, South Africa, had undiagnosed, culture-positive pulmonary tuberculosis. Despite WHO recommendations, neither cough nor AFB smear were adequately sensitive for screening. Tuberculosis sputum cultures should be performed before ART initiation, regardless of symptoms, in areas with a high prevalence of HIV and tuberculosis.
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Affiliation(s)
- Ingrid V Bassett
- Division of Infectious Disease, Massachusetts General Hospital, Boston, Massachusetts, USA.
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