Understanding the primary health care experiences of individuals who are homeless in non-traditional clinic settings

BACKGROUND

Despite the widespread implementation of Health Care for the Homeless programs that focus on comprehensive, integrated delivery systems of health care for people experiencing homelessness, engaging and retaining people experiencing homelessness in primary care remains a challenge. Few studies have looked at the primary care delivery model in non-traditional health care settings to understand the facilitators and barriers to engagement in care. The objective of our study was to explore the clinic encounters of individuals experiencing homelessness receiving care at two different sites served under a single Health Care for the Homeless program.

METHODS

Semi-structured interviews were conducted with people experiencing homelessness for an explorative qualitative study. We used convenience sampling to recruit participants who were engaged in primary care at one of two sites: a shelter clinic, n = 16, and a mobile clinic located in a church, n = 15. We then used an iterative, thematic approach to identify emergent themes and further mapped these onto the Capability-Opportunity-Motivation model.

RESULTS

Care accessibility, quality and integration were themes that were often identified by participants as being important facilitators to care. Psychological capability and capacity became important barriers to care in instances when patients had issues with memory or difficulty with perceiving psychological safety in healthcare settings. Motivation for engaging and continuing in care often came from a team of health care providers using shared decision-making with the patient to facilitate change.

CONCLUSION

To optimize health care for people experiencing homelessness, clinical interventions should: (1) utilize shared-decision making during the visit, (2) foster a sense of trust, compassion, and acceptance, (3) emphasize continuity of care, including consistent providers and staff, and (4) integrate social services into Health Care for the Homeless sites.

Ultra-deep sequencing data from a liquid biopsy proficiency study demonstrating analytic validity

Recently we reported the accuracy and reproducibility of circulating tumor DNA (ctDNA) assays using a unique set of reference materials, associated analytical framework, and suggested best practices. With the rapid adoption of ctDNA sequencing in precision oncology, it is critical to understand the analytical validity and technical limitations of this cutting-edge and medical-practice-changing technology. The SEQC2 Oncopanel Sequencing Working Group has developed a multi-site, cross-platform study design for evaluating the analytical performance of five industry-leading ctDNA assays. The study used tailor-made reference samples at various levels of input material to assess ctDNA sequencing across 12 participating clinical and research facilities. The generated dataset encompasses multiple key variables, including a broad range of mutation frequencies, sequencing coverage depth, DNA input quantity, etc. It is the most comprehensive public-facing dataset of its kind and provides valuable insights into ultra-deep ctDNA sequencing technology. Eventually the clinical utility of ctDNA assays is required and our proficiency study and corresponding dataset are needed steps towards this goal.

Measurement(s)	Somatic Mutation • spike-in quality control role
Technology Type(s)	Tumor Panel Sequencing
Factor Type(s)	Tumor Panel • DNA Library Input Quantity • Variant Allele Frequency
Sample Characteristic - Organism	Homo sapiens

Toward best practice in cancer mutation detection with whole-genome and whole-exome sequencing

Clinical applications of precision oncology require accurate tests that can distinguish true cancer-specific mutations from errors introduced at each step of next-generation sequencing (NGS). To date, no bulk sequencing study has addressed the effects of cross-site reproducibility, nor the biological, technical and computational factors that influence variant identification. Here we report a systematic interrogation of somatic mutations in paired tumor-normal cell lines to identify factors affecting detection reproducibility and accuracy at six different centers. Using whole-genome sequencing (WGS) and whole-exome sequencing (WES), we evaluated the reproducibility of different sample types with varying input amount and tumor purity, and multiple library construction protocols, followed by processing with nine bioinformatics pipelines. We found that read coverage and callers affected both WGS and WES reproducibility, but WES performance was influenced by insert fragment size, genomic copy content and the global imbalance score (GIV; G > T/C > A). Finally, taking into account library preparation protocol, tumor content, read coverage and bioinformatics processes concomitantly, we recommend actionable practices to improve the reproducibility and accuracy of NGS experiments for cancer mutation detection.

Projecting COVID-19 isolation bed requirements for people experiencing homelessness

As COVID-19 spreads across the United States, people experiencing homelessness (PEH) are among the most vulnerable to the virus. To mitigate transmission, municipal governments are procuring isolation facilities for PEH to utilize following possible exposure to the virus. Here we describe the framework for anticipating isolation bed demand in PEH communities that we developed to support public health planning in Austin, Texas during March 2020. Using a mathematical model of COVID-19 transmission, we projected that, under no social distancing orders, a maximum of 299 (95% Confidence Interval: 223, 321) PEH may require isolation rooms in the same week. Based on these analyses, Austin Public Health finalized a lease agreement for 205 isolation rooms on March 27th 2020. As of October 7th 2020, a maximum of 130 rooms have been used on a single day, and a total of 602 PEH have used the facility. As a general rule of thumb, we expect the peak proportion of the PEH population that will require isolation to be roughly triple the projected peak daily incidence in the city. This framework can guide the provisioning of COVID-19 isolation and post-acute care facilities for high risk communities throughout the United States.

Cross-oncopanel study reveals high sensitivity and accuracy with overall analytical performance depending on genomic regions

BACKGROUND

Targeted sequencing using oncopanels requires comprehensive assessments of accuracy and detection sensitivity to ensure analytical validity. By employing reference materials characterized by the U.S. Food and Drug Administration-led SEquence Quality Control project phase2 (SEQC2) effort, we perform a cross-platform multi-lab evaluation of eight Pan-Cancer panels to assess best practices for oncopanel sequencing.

RESULTS

All panels demonstrate high sensitivity across targeted high-confidence coding regions and variant types for the variants previously verified to have variant allele frequency (VAF) in the 5-20% range. Sensitivity is reduced by utilizing VAF thresholds due to inherent variability in VAF measurements. Enforcing a VAF threshold for reporting has a positive impact on reducing false positive calls. Importantly, the false positive rate is found to be significantly higher outside the high-confidence coding regions, resulting in lower reproducibility. Thus, region restriction and VAF thresholds lead to low relative technical variability in estimating promising biomarkers and tumor mutational burden.

CONCLUSION

This comprehensive study provides actionable guidelines for oncopanel sequencing and clear evidence that supports a simplified approach to assess the analytical performance of oncopanels. It will facilitate the rapid implementation, validation, and quality control of oncopanels in clinical use.

Integrating Prevention of Mother-to-Child Transmission of HIV Care into General Maternal Child Health Care in Western Kenya

BACKGROUND

Health systems integration is becoming increasingly important as the global health community transitions from acute, disease-specific health programming to models of care built for chronic diseases, primarily designed to strengthen public-sector health systems. In many countries across sub-Saharan Africa, including Kenya, prevention of mother-to-child transmission of HIV (pMTCT) services are being integrated into the general maternal child health (MCH) clinics. The objective of this study was to evaluate the benefits and challenges for integration of care within a developing health system, through the lens of an evaluative framework.

METHODS

A framework adapted from the World Health Organization's six critical health systems functions was used to evaluate the integration of pMTCT services with general MCH clinics in western Kenya. Perspectives were collected from key stakeholders, including pMTCT and MCH program leadership and local health providers. The benefits and challenges of integration across each of the health system functions were evaluated to better understand this approach.

RESULTS

Key informants in leadership positions and MCH staff shared similar perspectives regarding benefits and challenges of integration. Benefits of integration included convenience for families through streamlining of services and reduced HIV stigma. Concerns and challenges included confidentiality issues related to HIV status, particularly in the context of high-volume, crowded clinical spaces.

CONCLUSION AND GLOBAL HEALTH IMPLICATIONS

The results from this study highlight areas that need to be addressed to maximize the effectiveness and clinical flow of the pMTCT-MCH integration model. The lessons learned from this integration may be applied to other settings in sub-Saharan Africa attempting to integrate HIV care into the broader public-sector health system.

P6371Network characteristics of a hypertension referral system in western kenya

Introduction

The Strengthening Referral Networks for Management of Hypertension Across the Health System (STRENGTHS) trial is creating and testing interventions to improve the effectiveness of referral networks for patients with hypertension in Western Kenya.

Purpose

Network analysis of facility-based healthcare providers was used to understand the existing network of referrals. The ultimate goal was to identify both structural gaps and opportunities for implementation of the planned intervention.

Methods

A network survey was administered to providers who deliver care to patients with hypertension asking individuals to nominate a) individuals to whom, and b) facilities to which they refer patients, both up and down the health system. We analyzed survey data using centrality measures of in-degree and out-degree (number of links each provider received and sent, respectively), as well as fitting a core-periphery (CP) model. A higher CP indicates a strong referral network, while a lower CP indicates a relatively weaker network.

Results

Data were collected from 130 providers across 39 sites within 7 geographically separate network clusters. Each cluster consists of a mix of primary, secondary, and/or tertiary facilities. Compared to a perfect CP referral network model (Correlation Score [CP] = 1.00) and a random referral network model (CP = 0.200), the provider referral networks within each cluster showed a weak tendency for CP structure. There was a large range in CP from 0.334 to 0.639. In contrast, cluster-level facility networks showed a strong tendency for CP structure, with a CP range of 0.857 to 0.949.

Core Periphery Correlation Scores [CP] Network Cluster 1 Cluster 2 Cluster 3 Cluster 4 Cluster 5 Cluster 6 Cluster 7 Provider Referrals 0.433 0.424 0.334 0.639 0.535 0.448 0.407 Facility Referrals 0.949 0.894 0.871 0.949 0.949 0.904 0.857 Each cluster represents a geographically separate referral network. A random referral network would reveal a CP score of 0.200; while a perfect referral network would give a CP of 1.00.

Referral Network Models

Conclusions

The current health system across Western Kenya does not demonstrate a strong network of referrals between providers for patients with hypertension. While facility-to-facility referrals are more in-line with a perfect referral model, there are gaps in communication between the specific providers. These results highlight the need for STRENGTHS to design and test interventions that strengthen provider referral patterns in order to improve blood pressure control and reduce cardiovascular risk.

Acknowledgement/Funding

National Institutes of Health: National Heart Lung and Blood Institute, Doris Duke Charitable Foundation:International Clinical Research Fellowship

Leveraging peer-based support to facilitate HIV care in Kenya

Rakhi Karwa and colleagues discuss a program in which peer navigators support care for people with HIV at a Kenyan hospital.

Implementing intensified tuberculosis case-finding among street-connected youth and young adults in Kenya

BACKGROUND

Street-connected youth and young adults (SCY) suffer a myriad of health problems. In Kenya, SCY are at high risk for tuberculosis (TB) due to their congregate living situations. TB screening is not routinely implemented in SCY and there has been no published literature on the burden of TB in SCY in western Kenya.

PROGRAM DESCRIPTION

In 2011, the AMPATH TB Program, an experienced TB screening program, partnered with the Tumaini Center, a trusted street youth organization, to conduct intensified case finding (ICF) for pulmonary TB among SCY. Our program aimed to investigate the numbers of SCY who reported symptoms and those diagnosed with smear-positive pulmonary TB, and link SCY with TB to treatment.

RESULTS

Of 116 SCY who were screened, 114 (98%) had a positive questionnaire; 104 (90%) provided a spot sputum sample, 39 (34%) provided a morning sputum sample, and 111 (97%) reported cough of >2 weeks. One street youth tested smear-positive for TB and was treated through to cure.

CONCLUSIONS

Implementing TB ICF is feasible in low-resource settings through unique collaborations between health care programs and community-based organizations. In addition to identifying smear-positive TB, our program uncovered a high burden of respiratory symptoms among SCY in Eldoret, Kenya.

Improvement in quality of life of dialysis patients during six months of exercise

Quality of life (QOL) assessment has rapidly become an integral variable of outcome in clinical research; over 1,000 new articles each year are indexed under "quality of life" (1). Despite the proliferation of instruments and the burgeoning theoretical literature devoted to QOL evaluation, no unified approach has been derived for its measurement, and little agreement has been attained on what it means (2). Lack of clarity regarding the definition of QOL has led to several related concepts, namely functional status, life-satisfaction, well-being, and health status, being used interchangeably with QOL (3), further contributing to ambiguity. Compared to the general population, patients with end-stage renal disease (ESRD) experience a poorer QOL (4). Questionnaire-based QOL measurement in ESRD has demonstrated that QOL is best in renal transplantation and worst in unit-based haemodialysis. The main determinants of difference are the physical function domains. QOL in ESRD has traditionally been measured by a number of disease-specific, domain-specific and generic instruments, all exhibiting a fixed design. However, the fixed nature of the aforementioned instruments, is problematic in that what is measured is predetermined and hence may not represent the free choice of the individual whose QOL is assessed (5). Questionnaire-based instruments may not reflect individual priorities.

Acquisition of iron by Gardnerella vaginalis

Six Gardnerella vaginalis strains were examined for the ability to utilize various iron-containing compounds as iron sources. In a plate bioassay, all six strains acquired iron from ferrous chloride, ferric chloride, ferrous sulfate, ferric ammonium citrate, ferrous ammonium sulfate, bovine and equine hemin, bovine catalase, and equine, bovine, rabbit, and human hemoglobin. All six strains also acquired iron from human lactoferrin, but not from human transferrin, as determined by a liquid broth growth assay. Siderophore production was detected in eight G. vaginalis strains by the chrome azurol S universal chemical assay. Sodium dodecyl sulfate-polyacrylamide gel electrophoresis of the cytoplasmic membrane proteins isolated from G. vaginalis 594 grown under iron-replete and iron-restricted conditions revealed several iron-regulated proteins ranging in molecular mass from 33 to 94 kDa. These results indicate that G. vaginalis may acquire iron from iron salts and host iron compounds.

Evidence for the validity and utility of the Stages of Exercise Behaviour Change scale in young adults

This study examined the validity and utility of the Stages of Exercise Behaviour Change (SEBC) scale in 244 young British adults. One-way ANOVA revealed significant differences (F > 7.34, P < 0.01) between the Exercise Behaviour Change Categories of Precontemplation/Contemplation (n = 49), Preparation (n = 87) and Action/Maintenance (n = 108) in self-report levels of exercise behaviour. Significant differences (F > 3.14, P < 0.05) were also revealed in exercise self-efficacy, physical self-perception sub-domains and global self-esteem scores. Subsequent step-wise discriminant analyses revealed that discrimination between the Categories of Exercise Behaviour Change was possible on the basis of selected behavioural and psychological parameters (Canonical r = 0.76-0.82, Wilks' lambda = 0.30-0.33, chi 2 = 60.3-94.6, d.f. = 14, P < 0.0001). In both males and females, the most dominant discriminatory variables in the first Function were revealed to be perceived physical conditioning and 'strenuous' exercise behaviour. For males, the second Function comprised exercise self-efficacy and perceived bodily attractiveness, whilst for females it comprised perceived bodily attractiveness, perceived sports competence and perceived physical strength. Subsequent cross-validation analysis, using a randomly selected 40% sub-sample, revealed that 67.8-70.7% of subjects were assigned to the correct Category. These results appear to confirm the concurrent validity of the SEBC scale in terms of self-report of exercise behaviour. Furthermore, the utility of the SEBC scale was demonstrated via the ability to predict membership of specific Categories of Exercise Behaviour Change using a selection of behavioural and psychological parameters.