Krisda H. Chaiyachati

Interventions to improve adherence to antiretroviral therapy: a rapid systematic review.

Introduction:Access to antiretroviral treatment (ART) has substantially improved over the past decade. In this new era of HIV as a chronic disease, the continued success of ART will depend critically on sustained high ART adherence. The objective of this review was to systematically review interventions that can improve adherence to ART, including individual-level interventions and changes to the structure of ART delivery, to inform the evidence base for the 2013 WHO consolidated antiretroviral guidelines. Design:A rapid systematic review. Methods:We conducted a rapid systematic review of the global evidence on interventions to improve adherence to ART, utilizing pre-existing systematic reviews to identify relevant research evidence complemented by screening of databases for articles published over the past 2 years on evidence from randomized controlled trials (RCTs). We searched five databases for both systematic reviews and primary RCT studies (Cochrane Library, EMBASE, MEDLINE, Web of Science, and WHO Global Health Library); we additionally searched ClinicalTrials.gov for RCT studies. We examined intervention effectiveness by different study characteristics, in particular, the specific populations who received the intervention. Results:A total of 124 studies met our selection criteria. Eighty-six studies were RCTs. More than 20 studies have tested the effectiveness of each of the following interventions, either singly or in combination with other interventions: cognitive-behavioural interventions, education, treatment supporters, directly observed therapy, and active adherence reminder devices (such as mobile phone text messages). Although there is strong evidence that all five of these interventions can significantly increase ART adherence in some settings, each intervention has also been found not to produce significant effects in several studies. Almost half (55) of the 124 studies investigated the effectiveness of combination interventions. Combination interventions tended to have effects that were similar to those of single interventions. The evidence base on interventions in key populations was weak, with the exception of interventions for people who inject drugs. Conclusion:Tested and effective adherence-enhancing interventions should be increasingly moved into implementation in routine programme and care settings, accompanied by rigorous evaluation of implementation impact and performance. Major evidence gaps on adherence-enhancing interventions remain, in particular, on the cost-effectiveness of interventions in different settings, long-term effectiveness, and effectiveness of interventions in specific populations, such as pregnant and breastfeeding women.

A pilot study of an mHealth application for healthcare workers: poor uptake despite high reported acceptability at a rural South African community-based MDR-TB treatment program.

Introduction As the South African province of KwaZulu-Natal addresses a growing multidrug-resistant tuberculosis (MDR-TB) epidemic by shifting care and treatment from trained specialty centers to community hospitals, delivering and monitoring MDR-TB therapy has presented new challenges. In particular, tracking and reporting adverse clinical events have been difficult for mobile healthcare workers (HCWs), trained health professionals who travel daily to patient homes to administer and monitor therapy. We designed and piloted a mobile phone application (Mobilize) for mobile HCWs that electronically standardized the recording and tracking of MDR-TB patients on low-cost, functional phones. Objective We assess the acceptability and feasibility of using Mobilize to record and submit adverse events forms weekly during the intensive phase of MDR-TB therapy and evaluate mobile HCW perceptions throughout the pilot period. Methods All five mobile HCWs at one site were trained and provided with phones. Utilizing a mixed-methods evaluation, mobile HCWs’ usage patterns were tracked electronically for seven months and analyzed. Qualitative focus groups and questionnaires were designed to understand the impact of mobile phone technology on the work environment. Results Mobile HCWs submitted nine of 33 (27%) expected adverse events forms, conflicting with qualitative results in which mobile HCWs stated that Mobilize improved adverse events communication, helped their daily workflow, and could be successfully expanded to other health interventions. When presented with the conflict between their expressed views and actual practice, mobile HCWs cited forgetfulness and believed patients should take more responsibility for their own care. Discussion This pilot experience demonstrated poor uptake by HCWs despite positive responses to using mHealth. Though our results should be interpreted cautiously because of the small number of mobile HCWs and MDR-TB patients in this study, we recommend carefully exploring the motivations of HCWs and technologic enhancements prior to scaling new mHealth initiatives in resource poor settings.

Continuity in a VA Patient-Centered Medical Home Reduces Emergency Department Visits

Background One major goal of the Patient-Centered Medical Home (PCMH) is to improve continuity of care between patients and providers and reduce the utilization of non-primary care services like the emergency department (ED). Objective To characterize continuity under the Veterans Health Administration’s PCMH model – the Patient Aligned Care Team (PACT), at one large Veterans Affair’s (VA’s) primary care clinic, determine the characteristics associated with high levels of continuity, and assess the association between continuity and ED visits. Design Retrospective, observational cohort study of patients at the West Haven VA (WHVA) Primary Care Clinic from March 2011 to February 2012. Patients The 13,495 patients with established care at the Clinic, having at least one visit, one year before March 2011. Main Measures Our exposure variable was continuity of care –a patient seeing their assigned primary care provider (PCP) at each clinic visit. The outcome of interest was having an ED visit. Results The patients encompassed 42,969 total clinic visits, and 3185 (24%) of them had 15,458 ED visits. In a multivariable logistic regression analysis, patients with continuity of care – at least one visit with their assigned PCP – had lower ED utilization compared to individuals without continuity (adjusted odds ratio [AOR] 0.54; 95% CI: 0.41, 0.71), controlling for frequency of primary care visits, comorbidities, insurance, distance from the ED, and having a trainee PCP assigned. Likewise, the adjusted rate of ED visits was 544/1000 person-year (PY) for patients with continuity vs. 784/1000 PY for patients without continuity (pu200a=u200a0.001). Compared to patients with low continuity (<33% of visits), individuals with medium (33–50%) and high (>50%) continuity were less likely to utilize the ED. Conclusions Strong continuity of care is associated with decreased ED utilization in a PCMH model and improving continuity may help reduce the utilization of non-primary care services.

Distribution of Medical Education Debt by Specialty, 2010-2016

maintaining health insurance is a key protection against unmet need for prescription drugs in a nationally representative sample. However, having insurance does not guarantee coverage completeness or access to care. Patient cost sharing is increasing through higher deductibles, copayments, and coinsurance rates4 and medical financial hardship is increasingly documented in the United States,5 especially in relation to prescription drug use. Although findings were robust in sensitivity analyses, the study was limited by self-reported measures and lack of cost-sharing information. Self-reported unmet need may not correspond exactly to objective clinical measures. Prescription drug spending is projected to continue rising,1 increasing fiscal pressures on commercial, federal, state, and family budgets. For individuals with high drug costs, these trends may erode some of the protective effect of insurance coverage documented in this study. It is therefore imperative that research continue to monitor the relationship between insurance coverage and unmet need, assess spending and clinical outcomes, and that survey, administrative, and clinical data be available to do so.

Association of Rideshare-Based Transportation Services and Missed Primary Care Appointments: A Clinical Trial

Importance Transportation barriers contribute to missed primary care appointments for patients with Medicaid. Rideshare services have been proposed as alternatives to nonemergency medical transportation programs because of convenience and lower costs. Objective To evaluate the association between rideshare-based medical transportation and missed primary care appointments among Medicaid patients. Design, Setting, and Participants In a prospective clinical trial, 786 Medicaid beneficiaries who resided in West Philadelphia and were established primary care patients at 1 of 2 academic internal medicine practices located within the same building were included. Participants were allocated to being offered complimentary ride-sharing services (intervention arm) or usual care (control arm) based on the prescheduled day of their primary care appointment reminder. Those scheduled on even-numbered weekdays were in the intervention arm and on odd-numbered weekdays, the control arm. The primary study outcome was the rate of missed appointments, estimated using an intent-to-treat approach. All individuals receiving a phone call reminder were included in the study sample, regardless of whether they answered their phone. The study was conducted between October 24, 2016, and April 20, 2017. Interventions A model of providing rideshare-based transportation was designed. As part of usual care, patients assigned to both arms received automated appointment phone call reminders. As part of the study protocol, patients assigned to both arms received up to 3 additional appointment reminder phone calls from research staff 2 days before their scheduled appointment. During these calls, patients in the intervention arm were offered a complimentary ridesharing service. Research staff prescheduled rides for those interested in the service. After their appointment, patients phoned research staff to initiate a return trip home. Main Outcomes and Measures Missed appointment rate (no shows and same-day cancellations) in the intervention compared with control arm. Results Of the 786 patients allocated to the intervention or control arm, 566 (72.0%) were women; mean (SD) age was 46.0. (12.5) years. Within the intervention arm, 85 among 288 (26.0%) participants who answered the phone call used ridesharing. The missed appointment rate was 36.5% (144 of 394) for the intervention arm and 36.7% (144 of 392) for the control arm (Pu2009=u2009.96). Conclusions and Relevance The uptake of ridesharing was low and did not decrease missed primary care appointments. Future studies trying to reduce missed appointments should explore alternative delivery models or targeting populations with stronger transportation needs. Trial Registration clinicaltrials.gov Identifier: NCT02955433

Education Outcomes in a Duty-Hour Flexibility Trial in Internal Medicine

Background Concern persists that inflexible duty‐hour rules in medical residency programs may adversely affect the training of physicians. Methods We randomly assigned 63 internal medicine residency programs in the United States to be governed by standard duty‐hour policies of the 2011 Accreditation Council for Graduate Medical Education (ACGME) or by more flexible policies that did not specify limits on shift length or mandatory time off between shifts. Measures of educational experience included observations of the activities of interns (first‐year residents), surveys of trainees (both interns and residents) and faculty, and intern examination scores. Results There were no significant between‐group differences in the mean percentages of time that interns spent in direct patient care and education nor in trainees perceptions of an appropriate balance between clinical demands and education (primary outcome for trainee satisfaction with education; response rate, 91%) or in the assessments by program directors and faculty of whether trainees workload exceeded their capacity (primary outcome for faculty satisfaction with education; response rate, 90%). Another survey of interns (response rate, 49%) revealed that those in flexible programs were more likely to report dissatisfaction with multiple aspects of training, including educational quality (odds ratio, 1.67; 95% confidence interval [CI], 1.02 to 2.73) and overall well‐being (odds ratio, 2.47; 95% CI, 1.67 to 3.65). In contrast, directors of flexible programs were less likely to report dissatisfaction with multiple educational processes, including time for bedside teaching (response rate, 98%; odds ratio, 0.13; 95% CI, 0.03 to 0.49). Average scores (percent correct answers) on in‐training examinations were 68.9% in flexible programs and 69.4% in standard programs; the difference did not meet the noninferiority margin of 2 percentage points (difference, ‐0.43; 95% CI, ‐2.38 to 1.52; P=0.06 for noninferiority). Conclusions There was no significant difference in the proportion of time that medical interns spent on direct patient care and education between programs with standard duty‐hour policies and programs with more flexible policies. Interns in flexible programs were less satisfied with their educational experience than were their peers in standard programs, but program directors were more satisfied. (Funded by the National Heart, Lung, and Blood Institute and the ACGME; iCOMPARE ClinicalTrials.gov number, NCT02274818.)

Why Aren’t More Primary Care Residents Going into Primary Care? A Qualitative Study

ABSTRACTBACKGROUNDWorkforce projections indicate a potential shortage of up to 31,000 adult primary care providers by the year 2025. Approximately 80xa0% of internal medicine residents and nearly two-thirds of primary care internal medicine residents do not plan to have a career in primary care or general internal medicine.OBJECTIVEWe aimed to explore contextual and programmatic factors within primary care residency training environments that may influence career choices.DESIGNThis was a qualitative study based on semi-structured, in-person interviews.PARTICIPANTSThree primary care internal medicine residency programs were purposefully selected to represent a diversity of training environments. Second and third year residents were interviewed.APPROACHWe used a survey guide developed from pilot interviews and existing literature. Three members of the research team independently coded the transcripts and developed the code structure based on the constant comparative method. The research team identified emerging themes and refined codes. ATLAS.ti was used for the analysis.KEY RESULTSWe completed 24 interviews (12 second-year residents, and 12 third-year residents). The age range was 27–39 years. Four recurrent themes characterized contextual and programmatic factors contributing to residents’ decision-making: resident expectations of a career in primary care, navigation of the boundary between social needs and medical needs, mentorship and perceptions of primary care, and structural features of the training program.CONCLUSIONSAddressing aspects of training that may discourage residents from careers in primary care such as lack of diversity in outpatient experiences and resident frustration with their inability to address social needs of patients, and strengthening aspects of training that may encourage interests in careers in primary care such as mentorship and protected time away from inpatient responsibilities during primary care rotations, may increase the proportion of residents enrolled in primary care training programs who pursue a career in primary care.

Expanding Health Policy and Advocacy Education for Graduate Trainees.

BACKGROUNDnEducation in health policy and advocacy is recognized as an important component of health professional training. To date, curricula have only been assessed at the medical school level.nnnOBJECTIVEnWe sought to address the gap in these curricula for residents and other health professionals in primary care.nnnINNOVATIONnWe created a health policy and advocacy curriculum for the VA Connecticut Healthcare System, Center of Excellence in Primary Care Education, an interprofessional, ambulatory-based, training program that includes internal medicine residents, nurse practitioner fellows, health psychology fellows, and pharmacy residents. The policy module focuses on health care finance and delivery, and the advocacy module emphasizes negotiation skills and opinion-based writing. Trainee attitudes were surveyed before and after the course, and using the Wilcoxon signed rank test, relative change was determined. Knowledge acquisition was evaluated with precourse and postcourse examinations using a paired sample t test.nnnRESULTSnFrom July 2011 through June 2013, 16 trainees completed the course. In the postcourse survey, trainees demonstrated improved comfort with understanding health law and the American health care system (Likert mean increased from 2.1 to 3.0, Pu2009u200a=u200au2009.01), as well as with associated advocacy skills (Likert mean increased from 2.0 to 2.9, Pu2009u200a=u200au2009.04). Knowledge-based test scores also showed significant improvement (increasing from 55% to 78% correct, Pu2009≤u2009.001).nnnCONCLUSIONSnOur curriculum integrating core health policy knowledge with advocacy skills represents a novel approach in postgraduate health professional education and resulted in sustained improvement in knowledge and comfort with health policy and advocacy.

Patient Inducements — High Graft or High Value?

U.S. law prevents health care providers from using inducements to increase demand for care or encourage selection of one provider over another. But given recent changes in health care, perhaps inducements that support receipt of high-value services should be permitted.

Rideshare-Based Medical Transportation for Medicaid Patients and Primary Care Show Rates: A Difference-in-Difference Analysis of a Pilot Program

BackgroundTransportation to primary care is a well-documented barrier for patients with Medicaid, despite access to non-emergency medical transportation (NEMT) benefits. Rideshare services, which offer greater convenience and lower cost, have been proposed as an NEMT alternative.ObjectiveTo evaluate the impact of rideshare-based medical transportation on the proportion of Medicaid patients attending scheduled primary care appointments.DesignIn one of two similar practices, all eligible Medicaid patients were offered rideshare-based transportation (“rideshare practice”). A difference-in-difference analytical approach using logistic regression with robust standard errors was employed to compare show rate changes between the rideshare practice and the practice where rideshare was not offered (“control practice”).ParticipantsOur study population included residents of West Philadelphia who were insured by Medicaid and were established patients at two academic general internal medicine practices located in the same building.InterventionWe designed a rideshare-based transportation pilot intervention. Patients were offered the service during their reminder call 2 days before the appointment, and rides were prescheduled by research staff. Patients then called research staff to schedule their return trip home.Main MeasuresWe assessed the effect of offering rideshare-based transportation on appointment show rates by comparing the change in the average show rate for the rideshare practice, from the baseline period to the intervention period, with the change at the control practice.Key ResultsAt the control practice, the show rate declined from 60% (146/245) to 51% (34/67). At the rideshare practice, the show rate improved from 54% (72/134) to 68% (41/60). In the adjusted model, controlling for patient demographics and provider type, the odds of showing up for an appointment before and after the intervention increased 2.57 (1.10–6.00) times more in the rideshare practice than in the control practice.ConclusionsResults of this pilot program suggest that offering a rideshare-based transportation service can increase show rates to primary care for Medicaid patients.