Lauren Lipira

Disclosure of adverse events and errors in surgical care: challenges and strategies for improvement.

The disclosure of adverse events to patients, including those caused by medical errors, is a critical part of patient-centered healthcare and a fundamental component of patient safety and quality improvement. Disclosure benefits patients, providers, and healthcare institutions. However, the act of disclosure can be difficult for physicians. Surgeons struggle with disclosure in unique ways compared with other specialties, and disclosure in the surgical setting has specific challenges. The frequency of surgical adverse events along with a dysfunctional tort system, the team structure of surgical staff, and obstacles created inadvertently by existing surgical patient safety initiatives may contribute to an environment not conducive to disclosure. Fortunately, there are multiple strategies to address these barriers. Participation in communication and resolution programs, integration of Just Culture principles, surgical team disclosure planning, refinement of informed consent and morbidity and mortality processes, surgery-specific professional standards, and understanding the complexities of disclosing other clinicians’ errors all have the potential to help surgeons provide patients with complete, satisfactory disclosures. Improvement in the regularity and quality of disclosures after surgical adverse events and errors will be key as the field of patient safety continues to advance.

Psychosocial stressors and alcohol use, severity, and treatment receipt across human immunodeficiency virus (HIV) status in a nationally representative sample of US residents

ABSTRACT Background: Human immunodeficiency virus (HIV) is stigmatized and disproportionately impacts vulnerable populations. Thus, people living with HIV (PLWH) may have greater exposure to psychosocial stressors than those without HIV. Exposure to psychosocial stressors may increase alcohol use and serve as barriers to alcohol treatment receipt. The authors evaluate whether psychosocial stressors and alcohol use, symptom severity, and treatment receipt vary across HIV status in a general population sample of US residents and assess whether psychosocial stressors mediate identified associations. Methods: Data from Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) were used to assess associations between HIV status and psychosocial stressors (perceived stress, alcohol-related stigma, and perceived discrimination based on race/ethnicity, sexual orientation, or sex) and alcohol-related outcomes (any use, heavy drinking, symptom severity, and treatment receipt). For each outcome, regression models were fit and iteratively adjusted for sociodemographic characteristics and comorbidities. Indirect effects of HIV on alcohol-related outcomes through stressors were estimated to assess mediation when main effects were significant. Results: Among 34,653 NESARC Wave 2 respondents, 161 were PLWH. PLWH were more likely than those without HIV to experience discrimination and had higher levels of perceived stress than those without HIV (P values <.05), but the 2 groups did not differ regarding alcohol-related stigma. PLWH were less likely to use alcohol and had similar rates of heavy drinking relative to participants without HIV, but alcohol symptom severity and treatment receipt were greater among PLWH. Perceived stress but not discrimination mediated associations. Conclusions: Findings from this first study of variation in psychosocial stressors and alcohol use, severity, and treatment receipt across HIV status further highlight PLWH as a population that is particularly vulnerable to experiences of psychosocial stress and certain adverse alcohol-related outcomes. Future longitudinal research is needed in a larger sample of PLWH to identify intervention targets.

Input of stakeholders on reducing depressive symptoms and improving diabetes outcomes in India: Formative work for the INtegrated DEPrEssioN and Diabetes TreatmENT study

Context: Depression and diabetes are highly comorbid, adversely affecting treatment adherence, and resulting in poor outcomes. To improve treatment and outcomes for people dually affected by diabetes and depression in India, we aimed to develop and test an integrated care model. Aims: In the formative phase of this INtegrated DEPrEssioN and Diabetes TreatmENT (INDEPENDENT) study, we sought stakeholder perspectives to inform culturally-sensitive adaptations of the intervention. Settings and Design: At our Delhi, Chennai, and Visakhapatnam sites, we conducted focus groups for patients with diabetes and depression and interviewed health-care workers, family members, and patients. Subjects and Methods: Key informants were asked about experiences with diabetes and depression and for feedback on intervention materials. Analysis: Qualitative data were analyzed using a grounded theory approach. Results: Three major themes emerged that have bearing on adaptation of the proposed intervention: importance of family assistance, concerns regarding patient/family understanding of diabetes, and feedback regarding the proposed intervention (e.g., adequate time needed for implementation; training program, and intervention should address stigma). Conclusions: Based on our findings, the following components would add value when incorporated into the intervention: (1) engaging families in the treatment process, (2) clear/simple written information, (3) clear nonjargon verbal explanations, and (4) coaching to help patients cope with stigma.

Physician assistants and the disclosure of medical error.

Evolving state law, professional societies, and national guidelines, including those of the American Medical Association and Joint Commission, recommend that patients receive transparent communication when a medical error occurs. Recommendations for error disclosure typically consist of an explanation that an error has occurred, delivery of an explicit apology, an explanation of the facts around the event, its medical ramifications and how care will be managed, and a description of how similar errors will be prevented in the future. Although error disclosure is widely endorsed in the medical and nursing literature, there is little discussion of the unique role that the physician assistant (PA) might play in these interactions. PAs are trained in the medical model and technically practice under the supervision of a physician. They are also commonly integrated into interprofessional health care teams in surgical and urgent care settings. PA practice is characterized by widely varying degrees of provider autonomy. How PAs should collaborate with physicians in sensitive error disclosure conversations with patients is unclear. With the number of practicing PAs growing rapidly in nearly all domains of medicine, their role in the error disclosure process warrants exploration. The authors call for educational societies and accrediting agencies to support policy to establish guidelines for PA disclosure of error. They encourage medical and PA researchers to explore and report best-practice disclosure roles for PAs. Finally, they recommend that PA educational programs implement trainings in disclosure skills, and hospitals and supervising physicians provide and support training for practicing PAs.

Challenges in Recruiting African-Born, US-Based Participants for HIV and Tuberculosis Research

Research is critical for developing HIV and tuberculosis (TB) programming for U.S. African-born communities, and depends on successful recruitment of African-born people. From January 2014 to June 2016, we recruited African-born people for HIV and TB research in King County, Washington. We compared the characteristics of study participants and the underlying populations of interest, and assessed recruitment strategies. Target enrollment for the HIV study was 167 participants; 51 participants (31%) were enrolled. Target enrollment for the TB study was 218 participants; 38 (17%) were successfully recruited. Of 249 prior TB patients we attempted to contact by phone, we reached 72 (33%). Multiple recruitment strategies were employed with variable impact. Study participants differed from the underlying populations in terms of gender, country of origin and language. Inequities in research participation and in meaningful opportunities for such participation may exacerbate existing health disparities.

The role of service readiness and health care facility factors in attrition from Option B+ in Haiti: a joint examination of electronic medical records and service provision assessment survey data

Background Option B+ is a strategy wherein pregnant or breastfeeding women with HIV are enrolled in lifelong antiretroviral therapy (ART) for prevention of mother-to-child transmission (PMTCT) of HIV. In Haiti, attrition from Option B+ is problematic and variable across health care facilities. This study explores service readiness and other facility factors as predictors of Option B+ attrition in Haiti. Methods This analysis used longitudinal data from 2012 to 2014 from the iSanté electronic medical record system and cross-sectional data from Haitis 2013 Service Provision Assessment. Predictors included Service Availability and Readiness Assessment (SARA) measures for antenatal care (ANC), PMTCT, HIV care services and ART services; general facility characteristics and patient-level factors. Multivariable Cox proportional hazards models modelled the time to first attrition. Results Analysis of data from 3147 women at 63 health care facilities showed no significant relationships between SARA measures and attrition. Having integrated ANC/PMTCT care and HIV-related training were significant protective factors. Being a public-sector facility, having a greater number of quality improvement activities and training in ANC were significant risk factors. Conclusion Several facility-level factors were associated with Option B+ attrition. Future research is needed to explore unmeasured facility factors, clarify causal relationships, and incorporate community-level factors into the analysis of Option B+ attrition.

HIV-Related Stigma and Viral Suppression Among African-American Women: Exploring the Mediating Roles of Depression and ART Nonadherence

We used baseline data from a sample of African-American women living with HIV who were recruited to participate in a stigma-reduction intervention in Chicago and Birmingham (2013–2015) to (1) evaluate the relationship between HIV-related stigma and viral suppression, and (2) assess the role of depression and nonadherence to antiretroviral therapy (ART) as mediators. Data from women were included in this secondary analysis if they were on ART, had viral load data collected within 8-weeks of study entry and had complete covariate data. We used logistic regression to estimate the total effect of HIV-related stigma (14-item Stigma Scale for Chronic Illness) on viral suppression (< 200 copies/mL), and serial mediation analysis to estimate indirect effects mediated by depressive symptoms (8-item Patient Health Questionnaire) and ART nonadherence (number of days with missed doses). Among 100 women who met study inclusion criteria, 95% reported some level of HIV-related stigma. In adjusted models, higher levels of HIV-related stigma were associated with lower odds of being virally suppressed (AOR = 0.93, 95% CI = 0.89–0.98). In mediation analysis, indirect effects through depression and ART nonadherence were not significant. Findings suggest that HIV-related stigma is common among African-American women living with HIV, and those who experience higher levels of stigma are less likely to be virally suppressed. However, the mechanisms remain unclear.

“You are always hiding. It's the worst way to live.” Exploring Stigma in African Immigrants Living With HIV in a Large Northwest U.S. Metropolitan Area

&NA; African immigrants living in the United States are disproportionately and uniquely affected by HIV. Evidence shows that stigma may contribute to this inequity. Applying a biopsychosocial model of health, our qualitative study explored HIV‐related stigma and its impact on African immigrants living with HIV in a large northwestern U.S. metropolitan area. We conducted in‐depth, semi‐structured interviews with 20 African immigrants living with HIV. In the biological health realm, HIV‐related stigma contributed to adverse health care environments, disruptions in care, and poor physical health. In the psychological health realm, it was associated with emotional vulnerability, depressive symptoms, and negative coping. In the social health realm, stigma lead to disclosure challenges, isolation, and poor social support. HIV‐related stigma was an extensive and pervasive burden for this population. The biopsychosocial model was a helpful lens through which to explore HIV‐related stigma and identify opportunities for future research and intervention.

Evaluating the Impact of the Affordable Care Act on HIV Care, Outcomes, Prevention, and Disparities: A Critical Research Agenda

Abstract:In the United States (U.S.), health care policy plays a critical role in ensuring adequate care for people living with HIV (PLWH), eliminating new HIV infections, and reducing health disparities. The 2010 Patient Protection and Affordable Care Act (ACA) was designed to make health care more accessible, of higher quality, and more affordable. Many provisions of the ACA are considered relevant to HIV care and prevention. Because PLWH have unique care needs and many groups at risk for infection are members of vulnerable populations, timely and comprehensive evaluation of the ACA in terms of HIV is critical. In this paper, we discuss components of the ACA relevant to HIV care and prevention, describe their anticipated and initial effects, and finally, outline a research agenda to inform future HIV programming and policy.