Encampment Clearings And Transitional Housing: A Qualitative Analysis Of Resident Perspectives

The number of people experiencing homelessness in tent encampments in the US has increased significantly. Citing concerns over health and safety, many cities have pursued highly visible encampment removals. In January 2022, a major tent encampment in Boston, Massachusetts, was cleared using a unique approach: Most encampment residents were placed in transitional harm reduction housing. We conducted interviews between July 2022 and February 2023 with thirty former encampment residents to explore how the encampment clearing affected their health and sense of safety. We also explored participants' perspectives on harm reduction housing. Of those interviewed, fourteen people had been placed in such housing. Among those not placed, the encampment clearing tended to exacerbate health and safety concerns, especially those related to mental health conditions and risk for violence. Among people successfully placed, harm reduction housing improved health and safety and allowed participants to make meaningful progress toward long-term goals such as addiction recovery, management of chronic health conditions, and permanent housing. Our findings suggest that encampments can have safety-promoting characteristics, but if encampment removal is pursued, offering harm reduction housing after removal can be beneficial.

Findings from an Organizational Context Survey to Inform the Implementation of a Collaborative Care Study for Co-occurring Disorders

Primary care is an opportune setting to deliver treatments for co-occurring substance use and mental health disorders; however, treatment delivery can be challenging due multi-level implementation barriers. Documenting organizational context can provide insight into implementation barriers and the adaptation of new processes into usual care workflows. This study surveyed primary care and behavioral health staff from 13 clinics implementing a collaborative care intervention for opioid use disorders co-occurring with PTSD and/or depression as part of a multisite randomized controlled trial. A total of 323 completed an online survey for a 60% response rate. The Consolidated Framework for Implementation Research guided this assessment of multi-level factors that influence implementation. Most areas for improvement focused on inner setting (organizational level) constructs whereas individual-level constructs tended to be strengths. This work addresses a research gap regarding how organizational analyses can be used prior to implementation and provides practical implications for researchers and clinic leaders.

Facilitating exit from encampments: combining low-barrier transitional housing with stabilizing treatment for substance related problems

BACKGROUND

Tent encampments in the neighborhood surrounding Boston Medical Center (BMC) grew to include 336 individuals at points between 2019 and 21, prompting public health concerns. BMC, the City of Boston, and Commonwealth of Massachusetts partnered in 2/2022 to offer low-barrier transitional housing to encampment residents and provide co-located clinical stabilization services for community members with substance use disorders (SUDs) experiencing homelessness.

METHODS

To meet the needs of some of the people who had been living in encampments, BMC established in a former hotel: 60 beds of transitional housing, not contingent upon sobriety; and a low-barrier SUD-focused clinic for both housing residents and community members, offering walk-in urgent care, SUD medications, and infection screening/prevention; and a 24/7 short-stay stabilization unit to manage over-intoxication, withdrawal, and complications of substance use (e.g., abscesses, HIV risk, psychosis). A secure medication-dispensing cabinet allows methadone administration for withdrawal management. Housing program key metrics include retention in housing, transition to permanent housing, and engagement in SUD treatment and case management. Clinical program key metrics include patient volume, and rates of initiation of medication for opioid use disorder.

RESULTS

Housing: Between 2/1/22-1/31/2023, 100 people entered the low-barrier transitional housing (new residents admitted as people transitioned out); 50 former encampment residents and 50 unhoused people referred by Boston Public Health Commission. Twenty-five residents transferred to permanent housing, eight administratively discharged, four incarcerated, and four died (two overdoses, two other substance-related). The remaining 59 residents remain housed; none voluntarily returned to homelessness. One hundred residents (100%) engaged with case management, and 49 engaged with SUD treatment.

CLINICAL

In the first 12 months, 1722 patients (drawn from both the housing program and community) had 7468 clinical visits. The most common SUDs were opioid (84%), cocaine (54%) and alcohol (47%) and 61% of patients had a co-occurring mental health diagnosis in the preceding 24-months. 566 (33%) patients were started on methadone and accepted at an Opioid Treatment Program (OTP).

CONCLUSIONS

During the 1st year of operation, low-barrier transitional housing plus clinical stabilization care was a feasible and acceptable model for former encampment residents, 49% of whom engaged with SUD treatment, and 25% of whom transitioned to permanent housing.

Screening for opioid use disorder and co-occurring depression and post-traumatic stress disorder in primary care in New Mexico

BACKGROUND

Identifying patients in primary care services with opioid use disorder and co-occurring mental health disorders is critical to providing treatment. Objectives of this study were to (1) assess the feasibility of recruiting people to screen in-person for opioid use disorder and co-occurring mental health disorders (depression and/or post-traumatic stress disorder) in primary care clinic waiting rooms in preparation for a randomized controlled trial, and (2) compare results of detecting these disorders by universal in-person screening compared to electronic health record (EHR) diagnoses.

METHODS

This cross-sectional feasibility and pilot study recruited participants from four primary care clinics, two rural and two urban, from three health care organizations in New Mexico. Inclusion criteria were adults (≥ 18 years), attending one of the four clinics as a patient, and who spoke English or Spanish. Exclusion criteria were people attending the clinic for a non-primary care visit (e.g., dental, prescription pick up, social support). The main outcomes and measures were (1) recruitment feasibility which was assessed by frequencies and proportions of people approached and consented for in-person screening, and (2) relative differences of detecting opioid use disorder and co-occurring mental health disorders in waiting rooms relative to aggregate EHR data from each clinic, measured by prevalence and prevalence ratios.

RESULTS

Over two-weeks, 1478 potential participants were approached and 1145 were consented and screened (77.5% of patients approached). Probable opioid use disorder and co-occurring mental health disorders were identified in 2.4% of those screened compared to 0.8% in EHR. Similarly, universal screening relative to EHR identified higher proportions of probable opioid use disorder (4.5% vs. 3.4%), depression (17.5% vs. 12.7%) and post-traumatic stress disorder (19.0% vs. 3.6%).

CONCLUSIONS

Universal screening for opioid use disorder, depression, and post-traumatic stress disorder was feasible, and identified three times as many patients with these co-occurring disorders compared to EHR. Higher proportions of each condition were also identified, especially post-traumatic stress disorder. Results support that there are likely gaps in identification of these disorders in primary care services and demonstrate the need to better address the persistent public health problem of these co-occurring disorders.

Characteristics associated with the availability of therapeutic acupuncture in substance use disorder treatment facilities in the United States

BACKGROUND

We examine the characteristics associated with the availability of therapeutic acupuncture in substance use disorder (SUD) treatment facilities in the United States (US).

METHODS

This study utilizes data from the 2018 National Survey of Substance Abuse Treatment Services (N-SSATS). Multivariable logistic regression was performed.

RESULTS

Only 5.5% (n = 814) of all SUD treatment facilities offered acupuncture therapy. Facilities operating an opioid treatment program (OTP) were 1.60 times more likely to offer therapeutic acupuncture than non-OTP facilities. Facilities that offered oral naltrexone pharmacotherapy or buprenorphine with naloxone pharmacotherapy were 1.63 and 1.37 times more likely to offer therapeutic acupuncture, respectively, compared to facilities that did not offer these pharmacotherapies. Federal government facilities were over four times more likely to offer acupuncture than those operated by state governments and had triple the odds of having acupuncture than private nonprofit organizations. Tribal facilities were over five times more likely than state government-operated facilities to offer acupuncture. Facilities located in the Western region of the US were 1.59, 1.39, and 1.30 times more likely than Northeastern, Midwestern, and Southern US regions, respectively, to offer acupuncture therapy.

CONCLUSIONS

Although complementary and holistic approaches such as acupuncture are accepted adjunct methods to treat persons with SUD, the findings suggest that their utilization in SUD treatment facilities in the US is minimal. Results, however, highlight that facilities operated by tribal and federal governments, those that are located in the Western region of the US, and non-hospital facilities have the highest odds of incorporating therapeutic acupuncture as treatment for SUD.

Supplemental data for this article is available online at https://doi.org/10.1080/10550887.2022.2056401 .

Associations between discrimination and substance use among college students in the United States from 2015 to 2019

Discrimination has been associated with adverse health behaviors and outcomes, including substance use. Higher rates of substance use are reported among some marginalized groups, such as lesbian, gay, and bisexual populations, and have been partially attributed to discrimination. This study uses 2015-2019 National College Health Assessment data to determine whether college students reporting discrimination due to sexual orientation, race/ethnicity, gender, or age report greater substance use than their peers who do not report such experiences. Additionally, we assess exploratory questions regarding whether substance choices differ among students who reported facing discrimination. Over time, about 8.0% of students reported experiencing discrimination in the past year. After applying inverse probability treatment weights (IPTWs), exposure to discrimination was associated with an excess of 44 cases of marijuana use per 1000 students, an excess of 39 cases of alcohol use per 1000 students, and an excess of 11 cases of prescription painkiller use per 1000 students. Multivariable logistic regression models with IPTW demonstrated that students who experienced discrimination were more than twice as likely to use inhalants and methamphetamine. These students were also significantly more likely to use other drugs, including opiates, non-prescribed painkillers, marijuana, alcohol, hallucinogens, cocaine, and cigarettes; however, the differences with peers were smaller in magnitude. Students who experienced discrimination did not differ from peers who reported non-prescribed antidepressants use and were significantly less likely to use e-cigarettes and smokeless tobacco. Associations between discrimination and substance use vary by race, gender, sexual orientation, and age. These findings indicate that discrimination has significant associations with many kinds of substance use; however, the magnitude varies by substance type. More institutional efforts to address sources of discrimination affecting college students are needed.

Methadone initiation in a bridge clinic for opioid withdrawal and opioid treatment program linkage: a case report applying the 72-hour rule

Background

In the United States, methadone for opioid use disorder (OUD) is limited to highly regulated opioid treatment programs (OTPs), rendering it inaccessible to many patients. The “72-hour rule” allows non-OTP providers to administer methadone for emergency opioid withdrawal management while arranging ongoing care. Low-barrier substance use disorder (SUD) bridge clinics provide rapid access to buprenorphine but offer an opportunity to treat acute opioid withdrawal while facilitating OTP linkage. We describe the case of a patient with OUD who received methadone for opioid withdrawal in a bridge clinic and linked to an OTP within 72 h.

Case presentation

A 54-year-old woman with severe OUD was seen in a SUD bridge clinic requesting OTP linkage and assessed with a clinical opiate withdrawal scale (COWS) score of 12. She reported daily nasal use of 1 g heroin/fentanyl. Prior OUD treatment included buprenorphine-naloxone, which was only partially effective. Her acute opioid withdrawal was treated with a single observed oral dose of methadone 20 mg. She returned the following day with persistent opioid withdrawal (COWS score 11) and was treated with methadone 40 mg. On day 3, the patient was successfully admitted to a local OTP, where she remained engaged 3 months later.

Conclusions

While patients continue to face substantial access barriers, bridge clinics can play an important role in treating opioid withdrawal, building partnerships with OTPs to initiate methadone on demand, and preventing life-threatening delays to methadone treatment. Federal policy reform is urgently needed to make methadone more accessible to people with OUD.

Implementation of a Recuperation Unit and Hospitalization Rates Among People Experiencing Homelessness With COVID-19

This cohort study examines the association of the opening of a COVID-19 recuperation unit adjacent to a large safety-net hospital with COVID-19 hospitalization rates among people experiencing homelessness.

Caring for COVID's most vulnerable victims: a safety-net hospital responds

Background:

As COVID-19 surged in people experiencing homelessness, leaders at Boston Medical Center (BMC), New England’s largest safety-net hospital, developed a program to care for them.

Aim:

Provide an opportunity for COVID-infected people experiencing homelessness to isolate and receive care until no longer contagious

Setting:

A decommissioned hospital building.

Participants:

COVID-infected people experiencing homelessness

Program Description:

Care was provided by physician volunteers and furloughed staff. Care focused on allowing isolation, managing COVID-19 symptoms, harm-reduction interventions, and addressing problems related to substance use and mental illness.

Program evaluation:

Among 226 patients who received care, 65% were referred from BMC. Five percent were transferred to the hospital for a complication that appeared COVID-related. There were no deaths, but 7 patients had non-fatal overdoses. Seventy-nine % had at least one diagnosis of mental illness, and 42% reported actively using at least one substance at the time of admission. Thirty % had at least one mental health diagnosis plus active substance use.

Discussion:

This hospital-based COVID Recuperation Unit was rapidly deployed, provided safe isolation for 226 patients over 8 weeks, treated frequent SUD and mental illness, and helped prevent the hospital’s acute-care bed capacity from being overwhelmed during the peak of the COVID-19 epidemic.

Assessment of Oropharyngeal Specimens for Discontinuation of Transmission-Based COVID-19 Precautions

We compared oropharyngeal swab test performance with nasopharyngeal testing for discontinuation of transmission-based COVID-19 precautions. We performed a retrospective review of confirmed COVID-19-positive patients who received paired nasopharyngeal and oropharyngeal SARS-CoV-2 tests for clearance from isolation from May 4, 2020, to May 26, 2020. Using nasopharyngeal swabs as the reference standard, we calculated the sensitivity, specificity, and negative predictive value of oropharyngeal swabs. We also calculated the kappa between the 2 tests. A total of 189 paired samples were collected from 74 patients. Oropharyngeal swab sensitivity was 38%, specificity was 87%, and negative predictive value was 70%. The kappa was 0.25. Our study suggests that oropharyngeal swabs are inferior to nasopharyngeal swabs for test-based clearance from COVID-19 isolation.

Innovative virtual mentoring using the Extension for Community Healthcare Outcomes model for primary care providers for the management of alcohol use disorders

The number of experts available for the management of alcohol use disorders (AUDs) in rural and underserved areas in India is limited. In this study, a blended training programme was conducted for 26 primary care providers (PCPs) from nine districts of Bihar, in best practices for the management of AUDs. A two weeks on-site training was followed by fortnightly online tele-Extension for Community Healthcare Outcomes (ECHO) clinics for six months using the ‘Hub and Spokes’ ECHO model, accessible through internet-enabled smartphones. A questionnaire administered at baseline and after six months assessed changes in the PCPs compliance with principles of AUD management. Significant improvements were noted in compliance to principles in the management of AUDs based on self-report. Over the six months period 2695 individuals were screened, of whom 832 (30.8%) had an AUD Identification Test score of more than 16, indicating harmful use or dependence. The PCPs reported retaining 49.1 per cent of the cases for at least one follow up and needed to refer only 80 (3%) cases to specialists for further management. The ECHO model was found to be effective in training PCPs to provide quality healthcare. To confirm these findings, it needs to be tested in a large number of PCPs with a robust study design.

Strategies Used by Interprofessional Teams to Counter Healthcare Marginalization and Engage Complex Patients

Low-income U.S. patients with co-occurring behavioral and physical health conditions often struggle to obtain high-quality health care. The health and sociocultural resources of such "complex" patients are misaligned with expectations in most medical settings, which ask patients to mobilize forms of these assets common among healthier and wealthier populations. Thus, complex patients encounter barriers to engagement with their health behaviors and health care providers, resulting in poor outcomes. But this outcome is not inevitable. This study uses in-depth interviews with two interprofessional primary care teams and surveys of all six teams in a complex patient program to examine strategies for improving patient engagement. Five primary care team strategies are identified. While team member burnout was a common byproduct, professional support offered by the team structure reduced this effect. Team perspectives offer insight into mechanisms of improvement and the professional burdens and benefits of efforts to counter health care marginalization among complex patients.

A Novel Intervention for High-Need, High-Cost Medicaid Patients: a Study of ECHO Care

BACKGROUND

A small number of high-need patients account for a disproportionate amount of Medicaid spending, yet typically engage little in outpatient care and have poor outcomes.

OBJECTIVE

To address this issue, we developed ECHO (Extension for Community Health Outcomes) Care™, a complex care intervention in which outpatient intensivist teams (OITs) provided care to high-need high-cost (HNHC) Medicaid patients. Teams were supported using the ECHO model™, a continuing medical education approach that connects specialists with primary care providers for case-based mentoring to treat complex diseases.

DESIGN

Using an interrupted time series analysis of Medicaid claims data, we measured healthcare utilization and expenditures before and after ECHO Care.

PARTICIPANTS

ECHO Care served 770 patients in New Mexico between September 2013 and June 2016. Nearly all had a chronic mental illness, and over three-quarters had a chronic substance use disorder.

INTERVENTION

ECHO Care patients received care from an OIT, which typically included a nurse practitioner or physician assistant, a registered nurse, a licensed mental health provider, and at least one community health worker. Teams focused on addressing patients' physical, behavioral, and social issues.

MAIN MEASURES

We assessed the effect of ECHO Care on Medicaid costs and utilization (inpatient admissions, emergency department (ED) visits, other outpatient visits, and dispensed prescriptions.

KEY RESULTS

ECHO Care was associated with significant changes in patients' use of the healthcare system. At 12 months post-enrollment, the odds of a patient having an inpatient admission and an ED visit were each reduced by approximately 50%, while outpatient visits and prescriptions increased by 23% and 8%, respectively. We found no significant change in overall Medicaid costs associated with ECHO Care.

CONCLUSIONS

ECHO Care shifts healthcare utilization from inpatient to outpatient settings, which suggests decreased patient suffering and greater access to care, including more effective prevention and early intervention for chronic conditions.

ECHO Care: Providing Multidisciplinary Specialty Expertise to Support the Care of Complex Patients

BACKGROUND

Programs for high-need, high-cost (HNHC) patients can improve care and reduce costs. However, it may be challenging to implement these programs in rural and underserved areas, in part due to limited access to specialty consultation.

AIM

Evaluate the feasibility of using the Extension for Community Health Outcomes (ECHO) model to provide specialist input to outpatient intensivist teams (OITs) dedicated to caring for HNHC patients.

SETTING

Weekly group videoconferencing sessions that connect multidisciplinary specialists with OITs.

PARTICIPANTS

Six OITs across New Mexico, typically consisting of a nurse practitioner or physician assistant, a registered nurse, a counselor or social worker, and at least one community health worker.

PROGRAM DESCRIPTION

OITs and specialists participated in weekly teleECHO sessions focused on providing the OITs with case-based mentoring and support.

PROGRAM EVALUATION

OITs and specialists discussed 427 highly complex patient cases, many of which had social or behavioral health components to address. In 70% of presented cases, the teams changed their care plan for the patient, and 87% reported that they applied what they learned in hearing case presentations to other HNHC patients.

DISCUSSION

Pairing the ECHO model with intensive outpatient care is a feasible strategy to support OITs to provide high-quality care for HNHC patients.

Innovative telementoring for addiction management for remote primary care physicians: A feasibility study

OBJECTIVE

Addiction is a growing public health problem which affects the person, the whole family, and society. The primary care physician (PCP) is often the first point of contact in the health care and can play a significant role in the early detection and intervention. It is well established that early intervention is associated with better outcomes. In the formal medical training, PCPs receive no formal training on drug addiction management. In this pilot study, we developed an innovative telementoring model and looked at feasibility as well as acceptability among remote PCPs on drug addiction management.

MATERIALS AND METHODS

The telementoring model consists of both synchronous and asynchronous components. The synchronous component consists of National Institute of Mental Health And Neuro Sciences (NIMHANS) academic center Hub and remote district level primary care physician Spokes, and is implemented by using low-cost multipoint videoconference based tele-ECHO (Extension for Community Healthcare Outcome) clinics. During the tele-ECHO clinics, held fortnightly, the remote PCPs used Internet-enabled smartphones to connect as well as present the patient case summaries to the multidisciplinary expert team of NIMHANS HUB. The asynchronous component consists of mobile-based ubiquitous e-learning integrated to a course completion certificate. We evaluated this innovative telementoring program on participant engagement, learning, confidence, and satisfaction. A pre-post design and e-learning assignments were used to measure the outcomes.

RESULTS

Of the proposed 21 tele-ECHO clinics, 11 were held till the end of August 2017. All the PCPs were able to virtually join at least one tele-ECHO clinic. Out of 38 participants, two participated in all the tele-ECHO clinics and 47.36% (n = 18) attended more than six (>60% of total) tele-ECHO clinics. About 76.31% (n = 29) of the PCPs presented 41 patient case summaries. Among 38 PCPs, a cumulative of 89.47% completed three e-Learning assignments. The majority of participants (80%) used smartphone with 4G connections to join the tele-ECHO clinics. There was a significant change in knowledge gained over the time duration of 1-month (3.00 ± 0.86, P < 0.001) and 3-month (3.16 ± 0.90, P < 0.001) assessments compared to the baseline (1.77 ± 1.02). About 32.25% (n = 10) reported improved confidence level in managing a case of substance use disorder on a 10-point scale.

CONCLUSION

It has been feasible to connect an academic hub, i.e., NIMHANS to the PCPs of 36 remote districts of Bihar and conduct multipoint videoconference-based tele-ECHO clinics. The results indicate high participant retention. The learners are comfortable in adapting new technology-based learning as evidenced by high rate of e-learning assignment completion. These findings suggest that this new innovative learning model using technology can be an important modality for effective training to address management of drug addiction.

Effectiveness of NIMHANS ECHO blended tele-mentoring model on Integrated Mental Health and Addiction for counsellors in rural and underserved districts of Chhattisgarh, India

The present study was conducted to ascertain the effectiveness of Project ECHO, a Hub and Spokes tele-mentoring model to bridge the urban-rural divide in mental health and addiction care in the context of a developing country like India. The Counsellors from 11 rural and underserved districts of Chhattisgarh were periodically connected to NIMHANS multidisciplinary specialists by smartphone app and underwent virtual mentoring to learn and translate "best practices" in Mental health and Addiction by using "patient-centric learning", a core component of NIMHANS ECHO model. The outcome evaluation was modelled on Moore's evaluation framework focusing on participant engagement, satisfaction, learning, competence and performance. Over the period of 6 months i.e. 12 tele-ECHO clinics, 41 patients case summaries were discussed by the Counsellors with NIMHANS Hub Specialists. Half of the counsellors could join >80% clinics and overall there were no drop-outs. There was a significant increase in learning and self-confidence after six months. The participants liked "relevance of the courses to clinical practices". "group based discussions" and "a reduction in professionals isolation". The results indicate promise of the NIMHANS ECHO tele-mentoring model as one with potential for capacity-building in mental health and addiction for remote and rural areas by leveraging technology.

Project ECHO Brings Innovation to Community Health Worker Training and Support

ECHO is a movement to build capacity to provide best practice care for rural and underserved people all over the world. Community health workers are an integral part of this movement. Using videoconferencing technology to augment in-person training, ECHO creates a community of practice for case-based learning and ongoing support.

Contingent engagement: What we learn from patients with complex health problems and low socioeconomic status

OBJECTIVE

Elicit patients' perceptions of factors that facilitate their engagement in care METHODS: In-depth interviews with 20 adult Medicaid patients who had complex health problems, frequent hospitalizations/emergency department use, and who were enrolled in an intensive, team-based care program designed to address medical, behavioral, and social needs.

RESULTS

Prior to engaging in the program, participants described weak relationships with primary care providers, frequent hospitalizations and emergency visits, poor adherence to medications and severe social barriers to care. After participating in the program, participants identified key factors that enabled them to develop trust and engage with care including: availability for extended intensive interactions, a non-judgmental approach, addressing patients' material needs, and providing social contact for isolated patients. After developing relationships with their care team, participants described changes such as sustained interactions with their primary care team and incremental improvements in health behaviors.

CONCLUSION

These findings illuminate factors promoting "contingent engagement" for low socio-economic status patients with complex health problems, which allow them to become proactive in ways commensurate with their circumstances, and offers insights for designing interventions to improve patient outcomes.

PRACTICE IMPLICATIONS

For these patients, engagement is contingent on healthcare providers' efforts to develop trust and address patients' material needs.

Enhanced Primary Care Treatment of Behavioral Disorders With ECHO Case-Based Learning

The Extension for Community Healthcare Outcomes (ECHO) model offers a way for primary care providers to develop expertise in addressing behavioral health issues of primary care patients. It provides an alternative to traditional continuing medical education (CME) for ongoing training and support for health care providers. ECHO uses videoconferencing to connect multiple primary care teams simultaneously with academic specialists and builds capacity via mentorship and case-based learning. ECHO aims to expand access to care by developing capacity to treat common, complex conditions in underserved areas. Participants in an integrated addictions and psychiatry teleECHO program reported that when they presented a patient case, the feedback they received was highly valuable and led them to change their care plans more than 75% of the time. ECHO is an effective model for teaching primary care teams about behavioral health and may be more effective than traditional CME approaches.

Project ECHO (Extension for Community Healthcare Outcomes): A new model for educating primary care providers about treatment of substance use disorders

BACKGROUND

Project ECHO (Extension for Community Healthcare Outcomes) trains and mentors primary care providers (PCPs) in the care of patients with complex conditions. ECHO is a distance education model that connects specialists with numerous PCPs via simultaneous video link for the purpose of facilitating case-based learning. This article describes a teleECHO clinic based at the University of New Mexico Health Sciences Center that is focused on treatment of substance use disorders (SUDs) and behavioral health disorders.

METHODS

Since 2005, specialists in treatment of SUDs and behavioral health disorders at Project ECHO have offered a weekly 2-hour Integrated Addictions and Psychiatry (IAP) TeleECHO Clinic focused on supporting PCP evaluation and treatment of SUDs and behavioral health disorders. We tabulate the number of teleECHO clinic sessions, participants, and CME/CEU (continuing medical education/continuing education unit) credits provided annually. This teleECHO clinic has also been used to recruit physicians to participate in DATA-2000 buprenorphine waiver trainings. Using a database of the practice location of physicians who received the buprenorphine waiver since 2002, the number of waivered physicians per capita in US states was calculated. The increase in waivered physicians practicing in underserved areas in New Mexico was evaluated and compared with the rest of the United States.

RESULTS

Since 2008, approximately 950 patient cases have been presented during the teleECHO clinic, and more than 9000 hours of CME/CEU have been awarded. Opioids are the substances discussed most commonly (31%), followed by alcohol (21%) and cannabis (12%). New Mexico is near the top among US states in DATA-2000 buprenorphine-waivered physicians per capita, and it has had much more rapid growth in waivered physicians practicing in traditionally underserved areas compared with the rest of the United States since the initiation of the teleECHO clinic focused on SUDs in 2005.

CONCLUSION

The ECHO model provides an opportunity to promote expansion of access to treatment for opioid use disorder and other SUDs, particularly in underserved areas.

Demonopolizing medical knowledge

In the past 100 years, there has been an explosion of medical knowledge-and in the next 50 years, more medical knowledge will be available than ever before. Regrettably, current medical practice has been unable to keep pace with this explosion of medical knowledge. Specialized medical knowledge has been confined largely to academic medical centers (i.e., teaching hospitals) and to specialists in major cities; it has been disconnected from primary care clinicians on the front lines of patient care. To bridge this disconnect, medical knowledge must be demonopolized, and a platform for collaborative practice amongst all clinicians needs to be created. A new model of health care and education delivery called Project ECHO (Extension for Community Healthcare Outcomes), developed by the first author, does just this. Using videoconferencing technology and case-based learning, ECHO's medical specialists provide training and mentoring to primary care clinicians working in rural and urban underserved areas so that the latter can deliver the best evidence-based care to patients with complex health conditions in their own communities. The ECHO model increases access to care in rural and underserved areas, and it demonopolizes specialized medical knowledge and expertise.

Demonopolizing medical knowledge

In the past 100 years, there has been an explosion of medical knowledge-and in the next 50 years, more medical knowledge will be available than ever before. Regrettably, current medical practice has been unable to keep pace with this explosion of medical knowledge. Specialized medical knowledge has been confined largely to academic medical centers (i.e., teaching hospitals) and to specialists in major cities; it has been disconnected from primary care clinicians on the front lines of patient care. To bridge this disconnect, medical knowledge must be demonopolized, and a platform for collaborative practice amongst all clinicians needs to be created. A new model of health care and education delivery called Project ECHO (Extension for Community Healthcare Outcomes), developed by the first author, does just this. Using videoconferencing technology and case-based learning, ECHO's medical specialists provide training and mentoring to primary care clinicians working in rural and urban underserved areas so that the latter can deliver the best evidence-based care to patients with complex health conditions in their own communities. The ECHO model increases access to care in rural and underserved areas, and it demonopolizes specialized medical knowledge and expertise.

Outcomes of treatment for hepatitis C virus infection by primary care providers

BACKGROUND

The Extension for Community Healthcare Outcomes (ECHO) model was developed to improve access to care for underserved populations with complex health problems such as hepatitis C virus (HCV) infection. With the use of video-conferencing technology, the ECHO program trains primary care providers to treat complex diseases.

METHODS

We conducted a prospective cohort study comparing treatment for HCV infection at the University of New Mexico (UNM) HCV clinic with treatment by primary care clinicians at 21 ECHO sites in rural areas and prisons in New Mexico. A total of 407 patients with chronic HCV infection who had received no previous treatment for the infection were enrolled. The primary end point was a sustained virologic response.

RESULTS

A total of 57.5% of the patients treated at the UNM HCV clinic (84 of 146 patients) and 58.2% of those treated at ECHO sites (152 of 261 patients) had a sustained viral response (difference in rates between sites, 0.7 percentage points; 95% confidence interval, -9.2 to 10.7; P=0.89). Among patients with HCV genotype 1 infection, the rate of sustained viral response was 45.8% (38 of 83 patients) at the UNM HCV clinic and 49.7% (73 of 147 patients) at ECHO sites (P=0.57). Serious adverse events occurred in 13.7% of the patients at the UNM HCV clinic and in 6.9% of the patients at ECHO sites.

CONCLUSIONS

The results of this study show that the ECHO model is an effective way to treat HCV infection in underserved communities. Implementation of this model would allow other states and nations to treat a greater number of patients infected with HCV than they are currently able to treat. (Funded by the Agency for Healthcare Research and Quality and others.).

Expanding access to hepatitis C virus treatment--Extension for Community Healthcare Outcomes (ECHO) project: disruptive innovation in specialty care

The Extension for Community Healthcare Outcomes (ECHO) Model was developed by the University of New Mexico Health Sciences Center as a platform to deliver complex specialty medical care to underserved populations through an innovative educational model of team-based interdisciplinary development. Using state-of-the-art telehealth technology, best practice protocols, and case-based learning, ECHO trains and supports primary care providers to develop knowledge and self-efficacy on a variety of diseases. As a result, they can deliver best practice care for complex health conditions in communities where specialty care is unavailable. ECHO was first developed for the management of hepatitis C virus (HCV), optimal management of which requires consultation with multidisciplinary experts in medical specialties, mental health, and substance abuse. Few practitioners, particularly in rural and underserved areas, have the knowledge to manage its emerging treatment options, side effects, drug toxicities, and treatment-induced depression. In addition, data were obtained from observation of ECHO weekly clinics and database of ECHO clinic participation and patient presentations by clinical provider. Evaluation of the ECHO program incorporates an annual survey integrated into the ECHO annual meeting and routine surveys of community providers about workplace learning, personal and professional experiences, systems and environmental factors associated with professional practice, self-efficacy, facilitators, and barriers to ECHO. The initial survey data show a significant improvement in provider knowledge, self-efficacy, and professional satisfaction through participation in ECHO HCV clinics. Clinicians reported a moderate to major benefit from participation. We conclude that ECHO expands access to best practice care for underserved populations, builds communities of practice to enhance professional development and satisfaction of primary care clinicians, and expands sustainable capacity for care by building local centers of excellence.

Recruitment, genetic counseling, and BRCA testing for underserved women at a public hospital

Genetic counseling and testing for heritable susceptibility to breast cancer caused by mutations in BRCA genes are largely unavailable to underserved women in the United States. Starting in 2002 the UCSF Cancer Risk Program offered this service free of charge to poor and medically indigent women at San Francisco General Hospital (SFGH). One recruitment strategy was a single-page questionnaire in four languages administered to women waiting for mammograms at SFGH. This report analyzes our first 3 years of experience with the recruitment questionnaire and compares the patient demographics and BRCA test results at SFGH with a more typical population undergoing genetic counseling and testing at UCSF's Mt. Zion Hospital (MZH). To our knowledge this is the first comprehensive clinical service for hereditary breast cancer in a U.S. public hospital. The ethnic mix of all 350 patients counseled was Caucasian 49% (approximately 20% of Caucasians reported Ashkenazi Jewish ancestry), Latina, 26%; African American, 13%; and Asian/other, 12%. Compared to the MZH population, SFGH patients were more ethnically diverse, less educated and more likely to be unemployed. Of 72 patients tested for BRCA mutations, 51 (71%) were negative, 5 were BRCA1 positive, and 12 were BRCA2 positive. Four (1 Caucasian, 1 Latina, 2 African American) had a total of 13 BRCA variants of unknown significance (VUS). The ratio of BRCA1/BRCA2 positive SFGH patients (5/12) was reversed compared to MZH (119/91). We evaluated 4573 recruitment questionnaires and 280 (6%) were judged to represent a high risk of heritable cancer. After additional screening and referral negotiation, 74 were scheduled for counseling. We judged the recruitment questionnaire to be a feasible, efficient, and reasonably cost-effective way to identify women at high risk of hereditary cancer in a traditionally underserved population. Underserved populations present special challenges for genetic counselors because of large, geographically dispersed families, cultural taboos about cancer diagnoses, and social marginalization. Despite these complexities, the clinical service at SFGH has been well accepted by patients and staff. Our successful venture can serve as a model for other public hospitals contemplating this clinical service.

Risk-reducing salpingo-oophorectomy in BRCA mutation carriers: role of serial sectioning in the detection of occult malignancy

PURPOSE

Women who carry deleterious mutations of BRCA1 or BRCA2 genes have up to a 54% lifetime risk of developing ovarian cancer. After childbearing, women at high risk increasingly choose bilateral risk-reducing salpingo-oophorectomy (RRSO). Two recent studies of BRCA mutation carriers reported occult malignancy in 2.5% of women undergoing RRSO. This study aimed to increase this detection rate using a protocol.

METHODS

In 1996, the University of California San Francisco Gynecologic Oncology Program instituted a surgical-pathologic RRSO protocol that was composed of complete removal and serial sectioning of both ovaries and fallopian tubes, peritoneal and omental biopsies, and collection of peritoneal washings for cytology. We report the pathologic findings in 67 BRCA mutation carriers according to the degree of adherence to this protocol.

RESULTS

Of the 67 procedures, the protocol was followed completely or partially in 41 (61%). Seven occult malignancies were discovered, four in the fallopian tube and three in the ovaries. Six of these were microscopic, and all seven (17%) were found in specimens from complete or partial protocol procedures as opposed to standard procedures (P = .026). Other variables such as age, parity, BRCA1 or BRCA2 mutation, or type of surgery did not alter the strong effect of protocol procedure on the cancer detection rate.

CONCLUSION

A rigorous operative and pathologic protocol for RRSO increases the detection rate of occult ovarian malignancy in BRCA mutation carriers nearly seven-fold. If confirmed, this finding will alter postoperative management because additional staging, chemotherapy, and follow-up may be necessary in affected women.

Do patients choose physicians of their own race?

This study seeks to determine whether minority Americans tend to see physicians of their own race as a matter of choice or simply because minority physicians are more conveniently located within predominantly minority communities. Using data from the Commonwealth Fund 1994 National Comparative Survey of Minority Health Care, we found that black and Hispanic Americans sought care from physicians of their own race because of personal preference and language, not solely because of geographic accessibility. As minority populations continue to grow, the demand for minority physicians is likely to increase. Keeping up with this demand will require medical school admissions policies and physician workforce planning to include explicit strategies to increase the supply of underrepresented minority physicians.

Patient-physician racial concordance and the perceived quality and use of health care

BACKGROUND

Patients from racial and ethnic minority groups use fewer health care services and are less satisfied with their care than patients from the majority white population. These disparities may be attributable in part to racial or cultural differences between patients and their physicians.

OBJECTIVE

To determine whether racial concordance between patients and physicians affects patients' satisfaction with and use of health care.

METHODS

We analyzed data from the 1994 Commonwealth Fund's Minority Health Survey, a nationwide, telephone survey of noninstitutionalized adults. For the 2201 white, black, and Hispanic respondents who reported having a regular physician, we examined the association between patient-physician racial concordance and patients' ratings of their physicians, satisfaction with health care, reported receipt of preventive care, and reported receipt of needed medical care.

RESULTS

Black respondents with black physicians were more likely than those with nonblack physicians to rate their physicians as excellent (adjusted odds ratio [OR], 2.40; 95% confidence interval [CI], 1.55-3.72) and to report receiving preventive care (adjusted OR, 1.74; 95% CI, 1.01-2.98) and all needed medical care (adjusted OR, 2.94; 95% CI, 1.10-7.87) during the previous year. Hispanics with Hispanic physicians were more likely than those with non-Hispanic physicians to be very satisfied with their health care overall (adjusted OR, 1.74; 95% CI, 1.01-2.99).

CONCLUSIONS

Our findings confirm the importance of racial and cultural factors in the patient-physician relationship and reaffirm the role of black and Hispanic physicians in caring for black and Hispanic patients. Improving cultural competence among physicians may enhance the quality of health care for minority populations. In the meantime, by reducing the number of underrepresented minorities entering the US physician workforce, the reversal of affirmative action policies may adversely affect the delivery of health care to black and Hispanic Americans.

Accelerated lipoprotein uptake by transplantable hepatomas that express hepatic lipase

To test the hypothesis that hepatic lipase plays a key role in lipoprotein removal in vivo, a novel system was used. Hepatoma cells (HTC 7288c) were transfected with a cDNA encoding hepatic lipase in culture and grown as solid tumors in vivo. In culture, transfected cells degraded chylomicron remnants and low density lipoprotein (LDL) somewhat more efficiently than untransfected cells. Tumors from the transplanted cells produced hepatic lipase localized to the surface of tumors from transfected cells but not tumors from non-transfected cells, grown in the same rat. The tumors from transfected cells removed, per gm of tissue, 34% (P < 0.001) more 125I-labeled LDL than tumors from non-transfected cells in the same animal. The uptake of chylomicron remnants (by tumors from transfected cells) was also modestly enhanced (15 +/- 6%, P < 0.005). There were no differences in the uptake of 125I-labeled albumin or 125I-labeled asialoglycoprotein. Compared to the liver, the untransfected tumors took up 12%, and the transfected tumors took up about 18% as much LDL per gram of tissue. The uptake of chylomicron remnants compared to liver was far lower. Both types of tumors had about twice as much LDL receptor related protein as the liver. Wild-type tumors had the highest level of LDL receptor, twice hepatic lipase-secreting tumors, and six times that of the liver. Using the novel approach of transfecting transplantable tumor cells with hepatic lipase, the ability of hepatic lipase to facilitate the removal of apoB-containing lipoproteins was demonstrated. The liver still removes low density lipoprotein and especially chylomicron remnants more rapidly than the tumors, suggesting factors in addition to hepatic lipase and LDL receptor level play a major role in hepatic lipoprotein removal.

Unmet mental health needs of women in public-sector gynecologic clinics

OBJECTIVE

We examined the mental health needs of poor young women seen in public-sector gynecologic settings.

STUDY DESIGN

Participants were 205 ethnically diverse women, mean age 29 years, seen by gynecologists at San Francisco General Hospital, all either uninsured or receiving public medical assistance. An interview with an instrument designed to diagnose mood, anxiety, alcohol, and eating disorders in medical patients, the Prime-MD, was used to assess current mental disorders. Any history of sexual or other physical assault was recorded. Receipt of primary care was scored for comprehensiveness.

RESULTS

The rates of current psychiatric disorders were extremely high; 21.5% had current major depression. The prevalence of anxiety disorders was also elevated among these women. Many had a history of sexual trauma, and 28% had been the victims of unwanted intercourse. Finally, many reported behaviors that pose serious health risks. For example, 32% smoked and 2% used illicit drugs. Fewer than half had access to comprehensive primary medical care.

CONCLUSIONS

Young, poor women who seek care in public-sector gynecologic clinics would benefit from comprehensive medical care addressing their psychosocial needs.

Primary care and patient perceptions of access to care

BACKGROUND

Although much is known about how insurance affects access to care, it is unclear whether good primary care contributes to access. The purpose of this study was to determine how optimal primary care given by providers at a regular place of care, defined in terms of continuity, comprehensiveness, communication, and availability, contributed to perceptions of access to care in a large population-based probability sample of adults.

METHODS

Data were from a cross-sectional survey of 6674 English- and Spanish-speaking adults 18 to 64 years of age, randomly sampled from 41 urban California communities with a range of levels of access to care.

RESULTS

Following adjustment for sociodemographics and need for care, we found that having "optimal" primary care contributed independently to improved self-rated access, as did having health insurance, a regular place, and a regular provider. The largest difference n access was between having any health insurance and not having insurance. Once insurance was available, each additional element contributed in a cumulative manner to self-rated access. For those with insurance and a regular place, adding optimal primary care improved self-rated access to an extent similar to adding a regular provider.

CONCLUSIONS

We conclude that although providing insurance to the uninsured is the most effective means of improving self-rated access, the other elements each improve access as well. Once insurance and a regular place are provided, good primary care at that place may be equivalent to having a regular provider in terms of perceived access. Results support promotion of primary care as a model of health care that encourages good access.

Chinese hamster ovary cells expressing a cell surface-anchored form of hepatic lipase. Characterization of low density lipoprotein and chylomicron remnant uptake and selective uptake of high density lipoprotein-cholesteryl ester

The enzyme hepatic lipase may play several roles in lipoprotein metabolism. Recent investigation has suggested a role for the enzyme in lipoprotein and/or lipoprotein lipid uptake. To study this, a simple isolated system that mimics the in vivo system would be desirable. The enzyme is secreted by the hepatic parenchymal cell but exists, and presumably exerts its effects, while bound to capillary endothelial cells in the liver, adrenal gland, and the ovary. We constructed a cDNA that encodes the expression of a chimeric protein composed of rat hepatic lipase and the signal sequence for the addition of the glycophosphatidylinositol (GPI) anchor from human decay-accelerating factor. When transfected into Chinese hamster ovary (CHO) cells this gave rise to a cell population that had immunoreactive hepatic lipase on the cell surface. Cloning of the transfected cells produced several cell lines that expressed the chimeric protein bound to the cell surface by a GPI anchor. This was documented by demonstrating incorporation of [3H]ethanolamine into anti-hepatic lipase immunoprecipitable material; in addition, hepatic lipase was released from the cells by phosphatidylinositol-specific phospholipase C but not by heparin. Phosphatidylinositol-phospholipase C treatment of cells expressing the anchored lipase released material that comigrated with hepatic lipase on SDS-polyacrylamide gel electrophoresis and was immunoreactive with antibody to the cross-reacting determinant of GPI anchors. Cell lysates containing the anchored protein contained salt-resistant lipase activity, a known feature of the secreted hepatic lipase; thus it appears that these cells have a surface-anchored hepatic lipase molecule. Although it was not possible to demonstrate lipolysis by the enzyme while it was on the cell surface for technical reasons, the protein produced by these cells was active when studied in cell membranes. The ability of the cells to take up lipoproteins was studied. The cells demonstrated an increased affinity for low density lipoprotein (LDL) receptor mediated uptake of LDL. They did not, however, demonstrate any enhanced binding or removal of chylomicron remnants. With respect to LDL and remnants, the cells expressing anchored lipase behaved similarly to CHO cell that expressed secreted hepatic lipase. The cells expressing anchored hepatic lipase had a marked increase in the uptake of high density lipoprotein and high density lipoprotein cholesteryl ester when compared to that seen with CHO cells secreting hepatic lipase. This increase occurred primarily via the selective pathway, and was not reduced by addition of anti-LDL receptor or anti-hepatic lipase antibodies or the receptor-associated protein. Together the results suggest that hepatic lipase, when bound to the cell surface by a GPI anchor, plays a role in enhancing lipoprotein uptake. For LDL this may involve the provision of a second foot for particle binding, thus enhancing affinity for the LDL receptor. For chylomicron remnants an additional molecule or molecules are necessary to mediate this effect. For HDL, the enzyme facilitates uptake of cholesteryl ester primarily by the selective pathway.

Physician practice style and rates of hospitalization for chronic medical conditions

Hospitalization rates for chronic medical conditions vary across small areas and are associated inversely with community income. The authors studied whether variation in hospitalization rates can be attributed to differences in physician practice style. Using census and hospital discharge data, hospitalization rates were calculated for asthma, congestive heart failure, and diabetes in 40 medical service areas in California. The authors surveyed a random sample of 1,530 emergency physicians, general internists, and family and general practitioners in these areas, and measured clinical admission threshold by asking physicians whether they would hospitalize patients presented in 15 vignettes of graded severity. The authors measured social admission predisposition by asking how physicians' admission decisions would be influenced by social characteristics that increase patients' vulnerability to illness, including homelessness and drug use; 1,090 physicians responded (71%). There was significant variation across areas in both the clinical (P < 0.0001) and social (P < 0.001) admission scores. Variation in hospitalization rates correlated with physicians' clinical (r = .34, P = 0.03) and social (r = .36, P = 0.02) admission scores. However, in a multiple linear regression analysis that included community sociodemographic factors, physician practice style was not associated significantly with hospitalization rates. Physician practice style varies across areas, but does not explain variation in admission rates for chronic medical conditions after adjusting for community sociodemographic factors. Using methods such as practice guidelines or utilization review to re-set physicians' threshold for admission may not be effective in reducing hospitalizations for chronic medical conditions.

The role of black and Hispanic physicians in providing health care for underserved populations

BACKGROUND

Patients who are members of minority groups may be more likely than others to consult physicians of the same race or ethnic group, but little is known about the relation between patients' race or ethnic group and the supply of physicians or the likelihood that minority-group physicians will care for poor or black and Hispanic patients.

METHODS

We analyzed data on physicians' practice locations and the racial and ethnic makeup and socioeconomic status of communities in California in 1990. We also surveyed 718 primary care physicians from 51 California communities in 1993 to examine the relation between the physicians' race or ethnic group and the characteristics of the patients they served.

RESULTS

Communities with high proportions of black and Hispanic residents were four times as likely as others to have a shortage of physicians, regardless of community income. Black physicians practiced in areas where the percentage of black residents was nearly five times as high, on average, as in areas where other physicians practiced. Hispanic physicians practiced in areas where the percentage of Hispanic residents was twice as high as in areas where other physicians practiced. After we controlled for the racial and ethnic makeup of the community, black physicians cared for significantly more black patients (absolute difference, 25 percentage points; P < 0.001) and Hispanic physicians for significantly more Hispanic patients (absolute difference, 21 percentage points; P < 0.001) than did other physicians. Black physicians cared for more patients covered by Medicaid (P = 0.001) and Hispanic physicians for more uninsured patients (P = 0.03) than did other physicians.

CONCLUSIONS

Black and Hispanic physicians have a unique and important role in caring for poor, black, and Hispanic patients in California. Dismantling affirmative-action programs as is currently proposed, may threaten health care for both poor people and members of minority groups.

Relative roles of the LDL receptor, the LDL receptor-like protein, and hepatic lipase in chylomicron remnant removal by the liver

Studies were carried out in mice utilizing inhibitors of several cell surface molecules to evaluate their relative roles in chylomicron remnant removal. Anti-LDL receptor antibody inhibited approximately 45% of rapid remnant removal from plasma, prolonged their half life (63 s to 115 s) and reduced hepatic uptake by 45%. Receptor-associated protein (RAP) (1 mg/mouse), a high affinity inhibitor of the LDL receptor-related protein (LRP) and a low affinity inhibitor of the LDL receptor decreased remnant removal approximately 55%, prolonged the half life from 63 s to 230 s, and reduced hepatic uptake by 70%. RAP, but not anti-LDL receptor antibody, inhibited splenic uptake. With both injected together, an incremental effect was seen; plasma removal decreased 60%, T1/2 increased to 290 s, and hepatic uptake decreased by 80%. Thus, it is likely that virtually all of the very rapid removal of remnants from the plasma by the liver requires the presence of at least one of these members of the LDL receptor family. Anti-hepatic lipase antibody caused a small but significant delay in remnant removal from plasma and a larger decrease in hepatic uptake (22.5%). It doubled adrenal uptake. The anti-hepatic lipase antibody was not additive with either the anti-LDL receptor antibody or RAP. Anti-rat hepatic lipase antibody did not inhibit lipolysis by mouse hepatic lipase, suggesting that lipolysis is not the way hepatic lipase enhances remnant uptake. Hepatic lipase bound to remnants to a greater degree than it bound to other lipoproteins. Together these data suggest that hepatic lipase may serve as a binding site for chylomicron remnants, thereby enhancing their affinity for the liver surface, and thus removal by the proteins of the LDL receptor family. Other molecules may also play a role in removal from the circulation under conditions where the LDL receptor family receptors are absent or occupied.

Site-directed mutagenesis using thermostable enzymes

The two-primer method for site-directed mutagenesis facilitates the mutation of targets in double-stranded DNA. We have encountered difficulties using the original method for the mutagenesis of DNA cloned into pBluescript vectors, which is possibly due to the presence of regions of secondary structure that cannot be efficiently copied by the enzymes used. We report a modification of the two-primer method using the thermostable VentR DNA polymerase and Thermus aquaticus ligase, allowing an increase in reaction temperatures. The modified method is functional with the pBluescript family of vectors.

California physicians' willingness to care for the poor

Although generalist physicians appear to be more likely than specialists to provide care for poor adult patients, they may still perceive financial and nonfinancial barriers to caring for these patients. We studied generalist physicians' attitudes toward caring for poor patients using focus groups and used the results to design a survey that tested the generalizability of the focus group findings. The focus groups included a total of 24 physicians in 4 California communities; the survey was administered to a random sample of 177 California general internists, family physicians, and general practitioners. The response rate was 70%. Of respondents, 77% accepted new patients with private insurance; 31% accepted new Medicaid patients, and 43% accepted new uninsured patients. Nonwhite physicians were more likely to care for uninsured and Medicaid patients than were white physicians. In addition to reimbursement, nonfinancial factors played an important role in physicians' decisions not to care for Medicaid or uninsured patients. The perception of an increased risk of being sued was cited by 57% of physicians as important in the decision not to care for Medicaid patients and by 49% for uninsured patients. Patient characteristics such as psychosocial problems, being ungrateful for care, and noncompliance were also important. Poor reimbursement was cited by 88% of physicians as an important reason not to care for Medicaid patients and by 77% for uninsured patients. Policy changes such as universal health insurance coverage and increasing the supply of generalist physicians may not adequately improve access to care unless accompanied by changes that address generalist physicians' financial and nonfinancial concerns about providing care for poor patients.

Early induction of LDL receptor gene during rat liver regeneration

After partial hepatectomy in the rat, there is substantial lipid accumulation in the liver. No information is available on the possible role of receptor-mediated endocytosis in this process. Since the low density lipoprotein (LDL) receptor is stimulated as a part of an early growth response in cell culture (Ellsworth et al.: Biochem. J. 279:175-187, 1991), the metabolism of this receptor during liver regeneration was studied. The mRNA and membrane protein level of the receptor were measured in the liver and in the adrenal glands at different times after partial hepatectomy, corresponding to different phases of the cell cycle. A discontinuous pattern of receptor expression is detectable in the regenerating liver; a large increase of mRNA and membrane protein occurs at an early time (2-4 h), suggesting that there is induction of LDL receptor gene transcription shortly after partial hepatectomy. This response seems specific for the liver following injury since the adrenal receptor does not show a different pattern in partially hepatectomized rats and sham-operated controls. After returning to control levels, the LDL receptor again increases slightly above control at 24 h, a time when cell replication begins.

Sexual harassment in medical training

BACKGROUND

Sexual harassment has become a national concern and one that is increasingly recognized in the field of medicine. Although there are reports of the sexual harassment of medical trainees, there is little information on the prevalence of this problem and whether it is adequately addressed by training institutions.

METHODS

Surveys with descriptions and examples of sexual harassment were mailed to 133 internal medicine residents in a university training program. The residents were asked to report anonymously whether they had encountered sexual harassment during medical school or residency, the frequency and type of harassment, its effect on them, whether they chose to report it to a person in authority, and the factors that influenced this decision.

RESULTS

Surveys were returned by 82 residents (response rate, 62 percent), 33 women and 49 men. Twenty-four women (73 percent) and 11 men (22 percent) reported that they had been sexually harassed at least once during their training. The women were more likely than the men to have been physically harassed, and the women's harassers were of higher professional status. Among those harassed, 19 of the women (79 percent) and 5 of the men (45 percent) thought that the experience created a hostile environment or interfered with their performance at work, but only 2 women and no men reported their experiences to an authority. The women cited a lack of confidence that they would be helped as the main reason for not reporting the experience, whereas men most commonly said that they had dealt with the problem without the need for outside assistance.

CONCLUSIONS

Many medical trainees encounter what they believe to be sexual harassment during medical school or residency, and this often creates a hostile learning and work environment. Training institutions need to address the adverse effects this may have on medical education and patient care.

Hepatic lipase in the rat ovary. Ovaries cannot synthesize hepatic lipase but accumulate it from the circulation

Hepatic lipase is proposed to have a role in steroidogenesis through its involvement in the metabolism of high density lipoproteins. We examined the activity, synthesis, distribution, and uptake of this enzyme and assessed the content of its mRNA in luteinized ovaries. We found that during peak steroidogenesis, ovaries of pregnant mare's serum gonadotropin-human chorionic gonadotropin-treated immature rats contained heparin-releasable hepatic lipase-like activity which was neutralized in a dose-dependent manner by purified antibodies to hepatic lipase isolated from post-heparin perfusates of rat livers. Quantitative immunoelectron microscopy revealed that ovarian hepatic lipase occurred along endothelial cells and was 3-fold more abundant in blood vessels of corpora lutea than those of stroma. However, hepatic lipase was not synthesized by the ovary since radiolabeled enzyme was not immunoisolated from the medium of dispersed luteinized granulosa cells incubated with [35S]methionine whereas it was present in the medium of control cells (hepatocytes). Similarly, hepatic lipase mRNA was detectable in liver but not ovaries or kidneys by Northern or slot blot analyses or by the polymerase chain reaction. Finally, 125I-labeled hepatic lipase injected into tail veins was quickly cleared from the systemic circulation, accumulating in liver, ovaries, kidneys, and spleen. Subsequent heparin injection caused rapid reappearance of radioactivity in the bloodstream and a marked decline of radiolabel in liver and ovaries but a modest decrease of that in kidneys and none in spleen. Exogenous 125I-bovine serum albumin also accumulated in all four organs but was not displaced from liver or ovaries by subsequent administration of heparin. Taken together, these data suggest that steroidogenically active ovaries possess but do not synthesize hepatic lipase. Instead, hepatic lipase originating elsewhere, presumably in the liver, is accumulated from the circulation at heparin-sensitive sites in ovarian blood vessels.

Analysis of membrane and surface protein sequences with the hydrophobic moment plot

An algorithm has been developed which identifies alpha-helices involved in the interactions of membrane proteins with lipid bilayers and which distinguishes them from helices in soluble proteins. The membrane-associated helices are then classified with the aid of the hydrophobic moment plot, on which the hydrophobic moment of each helix is plotted as a function of its hydrophobicity. The magnitude of hydrophobic moment measures the amphiphilicity of the helix (and hence its tendency to seek a surface between hydrophobic and hydrophilic phases), and the hydrophobicity measures its affinity for the membrane interior. Segments of membrane proteins in alpha-helices tend to fall in one of three regions of a hydrophobic moment plot: (1) monomeric transmembrane anchors (class I HLA transmembrane sequences) lie in the region of highest hydrophobicity and smallest hydrophobic moment; (2) helices presumed to be paired (such as the transmembrane M segments of surface immunoglobulins) and helices which are bundled together in membranes (such as bacteriorhodopsin) fall in the adjacent region with higher hydrophobic moment and smaller hydrophobicity; and (3) helices from surface-seeking proteins (such as melittin) fall in the region with still higher hydrophobic moment. alpha-Helices from globular proteins mainly fall in a region of lower mean hydrophobicity and hydrophobic moment. Application of these methods to the sequence of diphtheria toxin suggests four transmembrane helices and a surface-seeking helix in fragment B, the moiety known to have transmembrane function.

An inexpensive semi-automated sequence reader for the Apple II computer

We describe a relatively inexpensive digitizing pad, available from Houston Instruments, for which we have written software which allows the direct reading of DNA (or RNA) sequencing gel autoradiographs. This eliminates several sources of error in nucleic acid sequencing, and renders computer analysis less cumbersome.