Evaluation of a hepatitis C clinical care coordination programme's effect on treatment initiation and cure: A surveillance-based propensity score matching approach

Hepatitis C (HCV) is a viral infection that if left untreated can severely damage the liver. Project INSPIRE was a 3 year HCV care coordination programme in New York City (NYC) that aimed to address barriers to treatment initiation and cure by providing patients with supportive services and health promotion. We examined whether enrolment in Project INSPIRE was associated with differences in HCV treatment and cure compared with a demographically similar group not enrolled in the programme. INSPIRE participants in 2015 were matched with a cohort of HCV-infected persons identified in the NYC surveillance registry, using full optimal matching on propensity scores and stratified by INSPIRE enrolment status. Conditional logistic regression was used to assess group differences in the two treatment outcomes. Two follow-up sensitivity analyses using individual pair-matched sets and the full unadjusted cohort were also conducted. Treatment was initiated by 72% (790/1130) of INSPIRE participants and 36% (11 960/32 819) of study-eligible controls. Among initiators, 65% (514/790) of INSPIRE participants compared with 47% (5641/11 960) of controls achieved cure. In the matched analysis, enrolment in INSPIRE increased the odds of treatment initiation (OR: 5.25, 95% CI: 4.47-6.17) and cure (OR: 2.52, 95% CI: 2.00-3.16). Results from the sensitivity analyses showed agreement with the results from the full optimal match. Participation in the HCV care coordination programme significantly increased the probability of treatment initiation and cure, demonstrating that care coordination for HCV-infected individuals improves treatment outcomes.

Telementoring of primary care providers delivering hepatitis C treatment in New York City: Results from Project INSPIRE

INTRODUCTION

The recent availability of highly effective, easily administered, and relatively nontoxic treatments for hepatitis C virus (HCV) infection provides an opportunity for clinicians to treat HCV in nonspecialist settings with appropriate support. Project INSPIRE provides care coordination to HCV patients and a web-based training program (telementoring) on disease management and treatment by HCV specialists to primary care providers inexperienced in HCV treatment. Weekly telementoring sessions use a didactic and case-based approach to instruct non-HCV providers on how to identify and assess HCV treatment candidates and prescribe appropriate treatment.

METHODS

We used mixed methods to assess the telementoring service, including provider surveys and semistructured interviews. Quantitative data were analyzed using descriptive statistics, and qualitative data were analyzed to identify dominant themes.

RESULTS

Provider survey responses indicated an increased ability to identify and evaluate HCV treatment candidates and increased confidence in sharing knowledge with peers and patients. Interviews revealed a high degree of satisfaction with the telementoring service and Project INSPIRE overall. The telementoring service was viewed as having enhanced providers' knowledge, confidence, and ability to treat their own HCV-infected patients rather than having to refer them to an HCV specialist with resulting benefits for continuity of care. Providers reported comradery and collegiality with other INSPIRE providers and satisfaction with professional growth from attaining new knowledge and skills via the telementoring service.

CONCLUSIONS

Using readily available web conferencing technology, telementoring can facilitate knowledge transfer between specialists and primary care providers, facilitating continuity of care for patients and increased provider satisfaction.

Successful treatment of chronic hepatitis C with triple therapy in an opioid agonist treatment program

BACKGROUND

People who inject drugs (PWID) constitute 10 million people globally with hepatitis C virus, including many opioid agonist treatment patients. Little data exist describing clinical outcomes for patients receiving HCV treatment with direct-acting antiviral agents (DAAs) in opioid agonist treatment settings.

METHODS

In this retrospective observational study, we describe clinical outcomes for 50 genotype-1 patients receiving HCV treatment with triple therapy: telaprevir (n=42) or boceprevir (n=8) in combination with pegylated interferon and ribavirin on-site in an opioid agonist treatment program.

RESULTS

Overall, 70% achieved an end of treatment response (ETR) and 62% achieved a sustained virological response (SVR). These treatment outcomes are nearly equivalent to previously published HCV outcomes shown in registration trials, despite high percentages of recent drug use prior to treatment (52%), ongoing drug use during treatment (45%) and psychiatric comorbidity (86%). Only 12% (n=6) discontinued antiviral treatment early for non-virological reasons. Four patients received a blood transfusion, and one discontinued telaprevir due to severe rash.

CONCLUSIONS

These data demonstrate that on-site HCV treatment with direct-acting antiviral agents is effective in opioid agonist treatment patients including patients who are actively using drugs. Future interferon-free regimens will likely be even more effective. Opioid agonist treatment programs represent an opportunity to safely and effectively treat chronic hepatitis C, and PWID should have unrestricted access to DAAs.

Effects of psychosocial support during labour and childbirth on breastfeeding, medical interventions, and mothers' wellbeing in a Mexican public hospital: a randomised clinical trial

OBJECT

To evaluate the effects of psychosocial support during labour, delivery and the immediate postpartum period provided by a female companion (doula).

DESIGN

The effects of the intervention were assessed by means of a randomised clinical trial. Social support by a doula was provided to women in the intervention group, while women in the control arm received routine care.

SETTING

A large social security hospital in Mexico City.

PARTICIPANTS

Seven hundred and twenty-four women with a single fetus, no previous vaginal delivery, < 6 cm of cervical dilatation, and no indications for an elective caesarean section were randomly assigned to be accompanied by a doula, or to receive routine care.

OUTCOME MEASURES

Breastfeeding practices, duration of labour, medical interventions, mother's emotional conditions, and newborn's health.

METHODS

Blinded interviewers obtained data from the clinical records, during encounters with women in the immediate postpartum period, and at their homes 40 days after birth. Relative risks and confidence intervals were estimated for all relevant outcomes.

RESULTS

The frequency of exclusive breastfeeding one month after birth was significantly higher in the intervention group (RR 1.64; I-C: 1.01-2.64), as were the behaviours that promote breastfeeding. However, the programme did not achieve a significant effect on full breastfeeding. More women in the intervention group perceived a high degree of control over the delivery experience, and the duration of labour was shorter than in the control group (4.56 hours vs 5.58 hours; RR 1.07 CI (95%) = 1.52 to -0.51). There were no effects either on medical interventions, mothers' anxiety, self-esteem, perception of pain and satisfaction, or in newborns' conditions.

CONCLUSIONS

Psychosocial support by doulas had a positive effect on breastfeeding and duration of labour. It had a more limited impact on medical interventions, perhaps because of the strict routine in hospital procedures, the cultural background of the women, the short duration of the intervention, and the profile of the doulas. It is important to include psychosocial support as a component of breastfeeding promotion strategies.

"Alone, I wouldn't have known what to do": a qualitative study on social support during labor and delivery in Mexico

This article presents some of the most relevant qualitative results of a trial to evaluate the effects of the provision of psychosocial support to first-time mothers during labor, childbirth and in the immediate postpartum period in a social security hospital in Mexico City. The article focuses on the experiences of mothers who have received psychosocial support from a doula (the term doula is used to identify a woman who provides continuous support to a woman during labor. delivery and the immediate postpartum period) and compares them with the experiences of those women who gave birth following normal hospital routine. Sixteen in-depth interviews were held with women in the immediate post partum period (eight of whom had been accompanied by a doula and eight who had not) before they were discharged from hospital, and the results were analyzed using qualitative techniques. The interviews showed that the women accompanied by a doula had a more positive childbirth experience. The differences between both groups related to their perceptions of the childbirth experience; the treatment they received from hospital staff; the information they were given and how well they understood it; their perception of hospital routines; their feelings about cesarean sections and, spatial and temporal perceptions. The most important difference between the two groups was the way they expressed their feelings about their own labor, their sense of control and their self-perception.

[Psychosocial support in pregnancy as a strategy to promote the newborn's health]

In this project we developed a social support and health education intervention meant to answer whether or not a program of this kind, within the present medical system, can improve perinatal outcomes. A multicenter randomized controlled trial was conducted in four Latin American countries. In Mexico, the project was carried out in a third level obstetric hospital. Patients were screened between the 15th and 22nd week of gestation. Inclusion criteria were factors associated with high risk of low birthweight. A total of 620 women were recruited, randomized and followed up during pregnancy and up to the 40th day post partum. Women in the intervention group were visited four to six times during pregnancy, could use a telephone hot line and a consultation service. A poster and a pamphlet meant to reinforce health education were handed out in the first visit. A "guided tour" for women at the end of pregnancy was organized periodically. Outcomes were measured in both groups at the 36th week of gestation, post partum and 40 days after delivery. Neonatal outcomes were obtained by blind interviewers from the clinical records. Neither in the multicenter nor in the Mexican sample were we able to modify the incidence of low birthweight and prematurity. However, in Mexico we obtained positive effects on birthweight and gestational age in the whole sample and in some specific strata. These results strongly suggest the convenience of replicating the study in Mexico.

Itraconazole for deep mycoses: preliminary experience in Mexico

Itraconazole has been used as oral therapy for deep mycoses since July 1984 in our institution. So far, therapy has been evaluated for eight patients: one with cutaneous coccidioidomycosis; two with chromomycosis (Fonsecaea pedrosoi); and five with sporotrichosis (three fixed, one lymphangitic, and one disseminated). Clinical and mycologic evaluations were done at the beginning of treatment, 15 days after the initiation of treatment, and monthly thereafter. Dosage was 100-200 mg per day, and duration of treatment was based on response. The cases of coccidioidomycosis and lymphangitic sporotrichosis were mycologically cured after two and seven months of treatment with 100 mg per day, respectively. The six other patients required higher doses. Two patients with sporotrichosis and one with chromomycosis were cured, and one patient with sporotrichosis and one with chromomycosis were markedly improved. In one patient with sporotrichosis, treatment was discontinued because of the slow response. No adverse reactions to treatment were reported.