Janet S. Choi

Effects of Community-Based Health Worker Interventions to Improve Chronic Disease Management and Care Among Vulnerable Populations: A Systematic Review

BACKGROUND Community-based health workers (CBHWs) are frontline public health workers who are trusted members of the community they serve. Recently, considerable attention has been drawn to CBHWs in promoting healthy behaviors and health outcomes among vulnerable populations who often face health inequities. OBJECTIVES We performed a systematic review to synthesize evidence concerning the types of CBHW interventions, the qualification and characteristics of CBHWs, and patient outcomes and cost-effectiveness of such interventions in vulnerable populations with chronic, noncommunicable conditions. SEARCH METHODS We undertook 4 electronic database searches-PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature, and Cochrane-and hand searched reference collections to identify randomized controlled trials published in English before August 2014. SELECTION We screened a total of 934 unique citations initially for titles and abstracts. Two reviewers then independently evaluated 166 full-text articles that were passed onto review processes. Sixty-one studies and 6 companion articles (e.g., cost-effectiveness analysis) met eligibility criteria for inclusion. DATA COLLECTION AND ANALYSIS Four trained research assistants extracted data by using a standardized data extraction form developed by the authors. Subsequently, an independent research assistant reviewed extracted data to check accuracy. Discrepancies were resolved through discussions among the study team members. Each study was evaluated for its quality by 2 research assistants who extracted relevant study information. Interrater agreement rates ranged from 61% to 91% (average 86%). Any discrepancies in terms of quality rating were resolved through team discussions. MAIN RESULTS All but 4 studies were conducted in the United States. The 2 most common areas for CBHW interventions were cancer prevention (n = 30) and cardiovascular disease risk reduction (n = 26). The roles assumed by CBHWs included health education (n = 48), counseling (n = 36), navigation assistance (n = 21), case management (n = 4), social services (n = 7), and social support (n = 18). Fifty-three studies provided information regarding CBHW training, yet CBHW competency evaluation (n = 9) and supervision procedures (n = 24) were largely underreported. The length and duration of CBHW training ranged from 4 hours to 240 hours with an average of 41.3 hours (median: 16.5 hours) in 24 studies that reported length of training. Eight studies reported the frequency of supervision, which ranged from weekly to monthly. There was a trend toward improvements in cancer prevention (n = 21) and cardiovascular risk reduction (n = 16). Eight articles documented cost analyses and found that integrating CBHWs into the health care delivery system was associated with cost-effective and sustainable care. CONCLUSIONS Interventions by CBHWs appear to be effective when compared with alternatives and also cost-effective for certain health conditions, particularly when partnering with low-income, underserved, and racial and ethnic minority communities. Future research is warranted to fully incorporate CBHWs into the health care system to promote noncommunicable health outcomes among vulnerable populations.

Rates of long-term cochlear implant use in children.

Objective To determine the rate of long-term cochlear implant (CI) use in children. Study Design Consecutive case series. Setting Tertiary referral center. Patients Approximately 474 patients younger than 18 years who received a first CI from 1999 to 2011. Interventions Cochlear implantation. Main Outcome Measure(s) Regular CI use, defined as using the CI for 8 hours or greater per day. Results We successfully contacted and obtained follow-up data on 402 patients (85%) via email, telephone, and postal survey. The rate of regular CI use was 93.2% (95% CI, 90.0–95.4) at 5 years postimplantation and 87.7% (95% CI, 82.9–91.3) at 10 years postimplantation. The mean number of hours of use per day was 12.0 hours (SD, 4.1 h). Cox proportional hazard regression analysis demonstrated a linear association between the age at implantation and the risk of discontinuing regular CI use. Rates of CI discontinuation increased by 18.2% per year of age at implantation (95% CI, 7.2%–30.4%). Reported reasons for CI use less than 8 hours per day include poor hearing benefit (53.2%), social pressure (21.3%), and recurrent displacement of the transmitter coil (17.0%). Conclusion High rates of regular CI use are sustained after childhood implantation, and younger age at implantation is associated with a higher rate of continued device usage.

Quality of life after intervention with a cochlear implant or hearing aid

To investigate the impact of hearing aid and cochlear implant use on quality of life in adults.

Association of Hearing Impairment and Anxiety in Older Adults

Objective: The objective of the study is was investigate the association between hearing impairment and anxiety. Method: We conducted a cross-sectional analysis of 1,732 community-based adults aged 76 to 85 years who participated in the Health Aging and Body Composition (ABC) study. Logistic regression models were adjusted for demographic and cardiovascular risk factors. Hearing impairment was defined by the speech-frequency pure tone average. Anxiety was defined as reporting two symptoms of at least “a little” or one symptom “quite a bit” on the three-item Hopkins Symptom Checklist. Results: Compared with individuals with no hearing impairment, the odds of prevalent anxiety were higher among individuals with mild hearing impairment (odds ratio [OR] = 1.32, 95% confidence interval [CI] = [1.01, 1.73]) and moderate or greater hearing impairment (OR = 1.59, 95% CI = [1.14, 2.22]). Hearing aid use was not significantly associated with lower odds of anxiety. Discussion: Hearing impairment is independently associated with greater odds of anxiety symptoms in older adults.

Long-term use of cochlear implants in older adults: Results from a large consecutive case series

Objective To investigate rates of long-term use of cochlear implants in a large, consecutive case series of older adults (≥60 yr). Study Design Consecutive case series. Setting Tertiary referral center. Patients Approximately 447 individuals 60 years or older who received their first CI from 1999 to 2011. We successfully contacted 397 individuals (89%) to ascertain data on the individual’s daily CI use averaged over the past 4 weeks. Intervention Cochlear implantation. Main Outcome Measure Regular CI use was defined as 8 hours or greater of use per day. We investigated the time from implantation to the date when an individual reported discontinuing regular CI use. Results The overall rate of regular CI use at 13.5 years of follow-up was 82.6% (95% CI, 72.5%–89.3%). Individuals who received a CI at 60 to 74 years had significantly higher rates of regular CI use at 13.5 years of follow-up (91.1% [95% CI, 83.2%–95.4%], n = 251) than individuals who received a CI at 75 years or older (55.7% [95% CI, 24.9%–78.1%], n = 146). The rate of discontinuing regular CI use (<8 hr/d) increased on average by 7.8% (95% CI, 3.0%–12.8%) per year of age at implantation. Conclusion Rates of long-term CI use in older adults at more than 10 years of follow-up exceed 80%. The rate of discontinuing regular CI use was strongly associated with older age at implantation. These results suggest that early implantation of older adults, once critically low levels of speech recognition are present, is associated with greater usage of the device.

Association of Hearing Impairment and Emotional Vitality in Older Adults

OBJECTIVES To better understand the potential impact of hearing impairment (HI) and hearing aid use on emotional vitality and mental health in older adults. METHOD We investigated the cross-sectional association of HI with emotional vitality in 1,903 adults aged 76-85 years in the Health ABC study adjusted for demographic and cardiovascular risk factors. Hearing was defined by the speech frequency pure tone average (no impairment < 25 dB, mild impairment 25-40 dB, and moderate or greater impairment > 40 dB). Emotional vitality was defined as having a high sense of personal mastery, happiness, low depressive symptomatology, and low anxiety. RESULTS Compared with individuals with no HI, participants with moderate or greater HI had a 23% lower odds of emotional vitality (odds ratio [OR] = 0.77; 95% confidence interval [CI]: 0.59-0.99). Hearing aid use was not associated with better emotional vitality (OR = 0.98; 95% CI: 0.81-1.20). DISCUSSION HI is associated with lower odds of emotional vitality in older adults. Further studies are needed to examine the longitudinal impact of HI on mental health and well-being.

A Comparison of Self-Report and Audiometric Measures of Hearing and Their Associations With Functional Outcomes in Older Adults

Objective: The aim was to investigate whether associations of hearing impairment (HI) with functional outcomes in older adults differ when using self-report versus pure-tone audiometry. Method: We examined 1,669 participants ≥70 years in National Health and Examination Survey from 2005-2006 and 2009-2010 whose hearing was assessed by self-report and pure-tone audiometry. We explored functional outcomes associated with audiometric HI (low physical activity, poor physical functioning, and hospitalization). Results: In adjusted models, we found significant associations of audiometric HI with both subjective and objective outcomes (e.g., dichotomous HI with self-reported difficulty in activities of daily living [ADLs], odds ratio [OR] = 1.47, 95% confidence interval [CI] [1.05, 2.06], and low accelerometer-measured physical activity, OR = 2.19, 95% CI [1.11, 4.34]). In contrast, self-reported HI was only associated with subjective outcomes and not with objective outcomes (e.g., dichotomous HI with difficulty in ADLs, OR = 1.63, 95% CI [1.12, 2.38], and low accelerometer-measured physical activity, OR = 0.95, 95% CI [0.66, 1.35]). Discussion: Results using self-reported hearing should not be considered representative of results using audiometry and may provide distinct aspects of HI in older adults.

The Baltimore HEARS Pilot Study: An Affordable, Accessible, Community-Delivered Hearing Care Intervention

Purpose of the Study Age-related hearing loss negatively affects health outcomes, yet disparities in hearing care, such as hearing aid use, exist based on race/ethnicity and socioeconomic position. Recent national efforts highlight reduction of hearing care disparities as a public health imperative. This study a) describes a community engagement approach to addressing disparities, b) reports preliminary outcomes of a novel intervention, and c) discusses implementation processes and potential for wide-scale testing and use. Design and Methods This was a prospective, randomized control pilot, with a 3-month delayed treatment group as a waitlist control, that assessed feasibility, acceptability, and preliminary efficacy of a community-delivered, affordable, and accessible intervention for older adults with hearing loss. Outcomes were assessed at 3 months, comparing immediate and delayed groups, and pooled to compare the cohorts pre- and 3-month post-intervention results. Results All participants completed the study (n = 15). The program was highly acceptable: 93% benefited, 100% would recommend the program, and 67% wanted to serve as future program trainers. At 3 months, the treated group (n = 8) experienced fewer social and emotional effects of hearing loss and fewer depressive symptoms as compared to the delayed treatment group (n = 7). Pooling 3-month post-intervention scores (n = 15), participants reported fewer negative hearing-related effects (effect size = -0.96) and reduced depressive symptoms (effect size = -0.43). Implications The HEARS (Hearing Equality through Accessible Research & Solutions) intervention is feasible, acceptable, low risk, and demonstrates preliminary efficacy. HEARS offers a novel, low-cost, and readily scalable solution to reduce hearing care disparities and highlights how a community-engaged approach to intervention development can address disparities.

Refractory Otitis Media and Sinonasal Disease in a Child

A 13-year-old boy presented to the pediatric emergency department (ED) with a history of left-sided otalgia. He initially presented 3 months ago to an outside ED with left-sided otalgia accompanied by intermittent serosanguinous otorrhea. He was diagnosed with acute otitis media with tympanic membrane (TM) rupture and was treated with a 7-day course of amoxicillin, which temporarily resolved the otorrhea. Three weeks ago, he presented to another facility with continuing left-sided otalgia and newly developed bleeding from his left ear. His symptoms were attributed to trauma from a cotton applicator, and he was sent home without treatment. One week ago, he presented to his pediatrician with a 1-week history of intermittent epistaxis and fevers up to 39.1°C. He was noted to have weight loss of 7 to 10 kg over the last 3 weeks. At that time, laboratory studies were remarkable only for elevated white blood cell count of 10.48 × 10/μL, prothrombin time of 13.1 seconds, and international normalized ratio of 1.3. Epstein-Barr virus and human immunodeficiency virus (HIV) serologies were negative. Chest X-ray was normal, and sinus X-ray showed opacification and mucosal thickening. He was started on amoxicillin clavulanate for presumed sinusitis. One week later, he returned to the ED without symptomatic improvement. His symptoms on presentation included fever, fatigue, weight loss, headache, otalgia, nasal congestion, rhinorrhea, facial pressure, epistaxis, and odynophagia. His past medical history included depression and seasonal allergies. Family history included Burkitt’s lymphoma, diabetes, hypertension, and depression. At this point, otolaryngology was consulted. Physical exam of his ears showed bilateral erythematous TMs without perforation and left middle ear effusion. Anterior rhinoscopy showed significant edema and erythema of his inferior turbinates, which were obstructing the nasal passages bilaterally. Computed tomography (CT) of the sinuses demonstrated near complete bilateral opacification of the paranasal sinuses, mastoid air cells, and middle ear space (Figure 1). He was admitted for presumed methicillin-resistant Staphylococcus aureus sinus infection after failing outpatient management of sinusitis and started on intravenous ceftriaxone and clindamycin.

Long-term Use of Cochlear Implants in Older Adults: Results from a Large Consecutive Case Series

Objectives: Investigate rates of long-term use of cochlear implants (CI) in a large, consecutive case series of older adults (≥ 60 years) and characteristics associated with continuing CI use. Methods: From 1999-2011, 447 individuals ≥60 years received their first CI at Johns Hopkins, and we successfully contacted 397 individuals (89%) to ascertain data on the individual’s daily CI use averaged over the past 4 weeks. Regular CI use was defined as ≥8 hours/d. We investigated the time from implantation to the date when an individual reported discontinuing regular CI use with Kaplan-Meier and Cox proportional hazard analyses. Results: The overall rate of regular CI use at 13.5 years of follow-up was 82.6% (95% confidence interval: 72.5-89.3%). Individuals who received a CI at 60-74 years had significantly higher rates of regular CI use at 13.5 years of follow-up (91.1%, [95% confidence interval: 83.2-95.4%], n = 251) than individuals who received a CI at ≥75 years (55.7%, [95% confidence interval: 24.9-78.1%], n = 146). The rate of discontinuing regular CI use (<8 hours per day) increased on average by 7.8% (95% confidence interval: 3.0-12.8%) per year of age at implantation. Conclusions: Rates of long-term CI use in older adults at >10 years of follow-up exceed 80%. The rate of discontinuing regular CI use was strongly associated with older age at implantation. These results suggest that the earlier implantation of older adults, once critically low levels of speech recognition are present, is associated with greater usage of the device.