Rachel J. Stern

A Community-Based Approach to Linking Injection Drug Users with Needed Services Through Pharmacies: An Evaluation of a Pilot Intervention in New York City

Studies suggest that community-based approaches could help pharmacies expand their public health role, particularly pertaining to HIV prevention. Thirteen pharmacies participating in New Yorks Expanded Syringe Access Program, which permits nonprescription syringe sales to reduce syringe-sharing among injection drug users (IDUs), were enrolled in an intervention to link IDU syringe customers to medical/social services. Sociodemographics, injection practices, beliefs about and experiences with pharmacy use, and medical/social service utilization were compared among 29 IDUs purchasing syringes from intervention pharmacies and 66 IDUs purchasing syringes from control pharmacies using chi-square tests. Intervention IDUs reported more positive experiences in pharmacies than controls; both groups were receptive to a greater public health pharmacist role. These data provide evidence that community-based participatory research aided in the implementation of a pilot structural intervention to promote understanding of drug use and HIV prevention among pharmacy staff, and facilitated expansion of pharmacy services beyond syringe sales in marginalized drug-using communities.

Comparison of injection drug users accessing syringes from pharmacies, syringe exchange programs, and other syringe sources to inform targeted HIV prevention and intervention strategies

OBJECTIVE To describe injection drug users (IDUs) who access syringes through different outlets to help inform the prevention needs of IDUs who underuse safe syringe sources in New York City (NYC), where syringe availability is high compared with other U.S. cities. DESIGN Cross sectional. SETTING NYC, 2005-2007. PARTICIPANTS 285 IDUs. INTERVENTION Participants were recruited using random street-intercept sampling in 36 socioeconomically disadvantaged neighborhoods. MAIN OUTCOME MEASURES IDUs using syringe exchange programs (SEPs), pharmacies, or other outlets as a primary syringe source were compared based on sociodemographic characteristics, injection practices, and medical service use. RESULTS Chi-square tests and polytomous logistic regression were used to compare IDUs with different self-reported primary syringe sources used in the 6 months preceding study entry. Compared with IDUs using other syringe sources, those primarily using SEPs were less likely to be black (adjusted odds ratio 0.26 [95% CI 0.11-0.57]), more likely to inject daily (3.32 [1.58-6.98]), and more likely to inject with a new syringe (2.68 [1.30-5.54]). Compared with IDUs using other syringe sources, those primarily using pharmacies were less likely to be black (0.39 [0.17-0.90]). CONCLUSION These data suggest that pharmacies and SEPs may be reaching different populations of IDUs and highlight a subpopulation of highly marginalized IDUs (i.e., black race, infrequent injectors) who are underusing safe syringe sources in NYC. Targeted interventions are needed to reduce racial disparities and increase use of safe syringe outlets.

Individual- and neighborhood-level factors associated with nonprescription counseling in pharmacies participating in the New York State Expanded Syringe Access Program

OBJECTIVE To determine the individual- and neighborhood-level predictors of frequent nonprescription in-pharmacy counseling. DESIGN Descriptive, nonexperimental, cross-sectional study. SETTING New York City (NYC) during January 2008 to March 2009. INTERVENTION 130 pharmacies registered in the Expanded Syringe Access Program (ESAP) completed a survey. PARTICIPANTS 477 pharmacists, nonpharmacist owners/managers, and technicians/clerks. MAIN OUTCOME MEASURES Frequent counseling on medical conditions, health insurance, and other products. RESULTS Technicians were less likely than pharmacists to provide frequent counseling on medical conditions or health insurance. Regarding neighborhood-level characteristics, pharmacies in areas of high employment disability were less likely to provide frequent health insurance counseling and pharmacies in areas with higher deprivation were more likely to provide counseling on other products. CONCLUSION ESAP pharmacy staff members are a frequent source of nonprescription counseling for their patients in disadvantaged neighborhoods of NYC. These findings suggest that ESAP pharmacy staff may be amenable to providing relevant counseling services to injection drug users and warrant further investigation.

Advances in measuring culturally competent care: a confirmatory factor analysis of CAHPS-CC in a safety-net population.

Background:Providing culturally competent care shows promise as a mechanism to reduce health care inequalities. Until the recent development of the Consumer Assessment of Healthcare Providers and Systems Cultural Competency Item Set (CAHPS-CC), no measures capturing patient-level experiences with culturally competent care have been suitable for broad-scale administration. Methods:We performed confirmatory factor analysis and internal consistency reliability analysis of CAHPS-CC among patients with type 2 diabetes (n=600) receiving primary care in safety-net clinics. CAHPS-CC domains were also correlated with global physician ratings. Results:A 7-factor model demonstrated satisfactory fit (&khgr;2 231=484.34, P<0.0001) with significant factor loadings at P<0.05. Three domains showed excellent reliability—Doctor Communication-Positive Behaviors (&agr;=0.82), Trust (&agr;=0.77), and Doctor Communication-Health Promotion (&agr;=0.72). Four domains showed inadequate reliability either among Spanish speakers or overall (overall reliabilities listed): Doctor Communication-Negative Behaviors (&agr;=0.54), Equitable Treatment (&agr;=0.69), Doctor Communication-Alternative Medicine (&agr;=0.52), and Shared Decision-Making (&agr;=0.51). CAHPS-CC domains were positively and significantly correlated with global physician rating. Conclusions:Select CAHPS-CC domains are suitable for broad-scale administration among safety-net patients. Those domains may be used to target quality-improvement efforts focused on providing culturally competent care in safety-net settings.

Associations between aspects of culturally competent care and clinical outcomes among patients with diabetes.

Background:Culturally competent care may be associated with clinical outcomes in diabetes management, which requires effective physician-patient collaboration. The recent development and validation of the Consumer Assessment of Healthcare Providers and Systems Cultural Competence tool enables investigation of possible associations. Objective:To assess whether 3 aspects of culturally competent care are associated with glycemic, lipid, and blood pressure control among ethnically diverse patients with diabetes. Design:Survey and chart review study of patients recruited from urban safety net clinics in 2 cities. Subjects:A total of 600 patients with type 2 diabetes and a primary care physician. Measures:We used multivariate logistic regression to assess the independent relationships between the 3 domains of the Consumer Assessment of Healthcare Providers and Systems Cultural Competence (Doctor Communication-Positive Behaviors, Trust, and Doctor Communication-Health Promotion) and glycemic, lipid, and systolic blood pressure control after adjusting for sociodemographic and clinical factors. Results:In adjusted analysis, high Trust was associated with lower likelihood of poor glycemic control (odds ratio, 0.59; 95% confidence interval, 0.41–0.84) and high Doctor Communication-Health Promotion was associated with a higher likelihood of poor glycemic control (odds ratio, 1.49, 95% CI, 1.02–2.19). None of the 3 aspects of culturally competent care examined were associated with lipid or systolic blood pressure control after adjustment. Discussion:Trust in physician, a core component of culturally competent care, but not doctor communication behavior, was associated with a lower likelihood of poor glycemic control in a safety net population with diabetes. Glycemic control may be more sensitive to patient physician partnership than blood pressure and hyperlipidemia control.

Risk factors for reporting poor cultural competency among patients with diabetes in safety net clinics.

Background:The Consumer Assessment of Healthcare Providers and Systems Cultural Competency Item Set assesses patient perceptions of aspects of the cultural competence of their health care. Objective:To determine characteristics of patients who identify the care they receive as less culturally competent. Research Design:Cross-sectional survey consisting of face-to-face interviews. Subjects:Safety-net population of patients with type 2 diabetes (n=600) receiving ongoing primary care. Measures:Participants completed the Consumer Assessment of Healthcare Providers and Systems Cultural Competency and answered questions about their race/ethnicity, sex, age, education, health status, depressive symptoms, insurance coverage, English proficiency, duration of relationship with primary care provider, and comorbidities. Results:In adjusted models, depressive symptoms were significantly associated with poor cultural competency in the Doctor Communication—Positive Behaviors domain [odds ratio (OR) 1.73, 95% confidence interval, 1.11–2.69]. African Americans were less likely than whites to report poor cultural competence in the Doctor Communication—Positive Behaviors domain (OR 0.52, 95% CI, 0.28–0.97). Participants who reported a longer relationship (≥3 y) with their primary care provider were less likely to report poor cultural competence in the Doctor Communication—Health Promotion (OR 0.35, 95% CI, 0.21–0.60) and Trust domains (OR 0.4, 95% CI, 0.24–0.67), whereas participants with lower educational attainment were less likely to report poor cultural competence in the Trust domain (OR 0.51, 95% CI, 0.30–0.86). Overall, however, sociodemographic and clinical differences in reports of poor cultural competence were insignificant or inconsistent across the various domains of cultural competence examined. Conclusions:Cultural competence interventions in safety-net settings should be implemented across populations, rather than being narrowly focused on specific sociodemographic or clinical groups.

Metformin as Initial Oral Therapy in Type 2 Diabetes

1.68; 95% CI, 1.57-1.79), thiazolidinediones (HR, 1.61; 95% CI, 1.43-1.80), and dipeptidyl peptidase 4 inhibitors (HR, 1.62; 95% CI, 1.47-1.79) was associated with an increased hazard of intensification. Alternatives to metformin were not associated with a reduced risk of hypoglycemia, emergency department visits, or cardiovascular events.

Firearm Injuries and Gun Violence: Call for Papers

In 2013, firearm injurieswere responsible for 33636deaths in theUnitedStates,almost thesamenumberas the33804deaths frommotorvehiclecrashes.1Thetotals include21 175suicides— about half of all deaths classified as suicides—and 11 208 homicides—about70%ofall deaths classifiedashomicides. Since 2000, deaths from motor vehicle crashes have substantially decreased; in contrast, deaths from firearm injuries have substantially increased,mostly fromsuicides (Figure).Massshootings, such as the killings of school children and educators at SandyHook Elementary School in Newtown, Connecticut, in 2012 and of public healthworkers in San Bernardino, California, in 2015, continue to shock the public conscience. If the United States were to implement a coordinated and sustainedpublichealth,medical, and law-enforcementeffort to prevent firearminjuriesanddeaths, thousandsof livesmightbe saved each year.2 Yet, as is well known, federal law effectively prohibits federal supportofgunresearch,3 andCongresshas repeatedly continued this ban. Federal officials, other thanPresident Obama, rarely speak out or provide public leadership. JAMAInternalMedicine is launchinga serieson firearm injuries and gun violence. Research is hindered by limitations onfundingandthepassionsandcontroversiesabout thesesubjects. Research, however, is essential for the United States to have an informedandeffectivepublic health response.We invite submissions of original research (Original Investigations andResearchLetters).Wearealso interested in scholarlyViewpoints thatadvanceconstructivepolicyproposals andwill consider Reviews and Special Communications. If authorshavequestionsabout this seriesof articlesorany other submission issues related to firearminjuriesandgunviolence, please feel free to contact us. For guidelines onmanuscript submission and preparation, please consult the JAMA Internal Medicine Instructions for Authors.4 In recent years, general medical journals have published few research articles about firearm injuries and gun violence. There have been exceptions, such as the study by Fleegler et al5 about the association between a higher number of firearm laws ina state and“a lower rateof firearmfatalities in the state, overall and for suicides andhomicides individually.”5(p732) The reasoncouldbethat theresearcharticleswemightwant topublish are not being written because there are too few researchers and too little research. We do not know. We hope to find out and tohaveour skepticismprovenwrong.The time is right to respond to the epidemic of firearm injuries and gun violencewith high-quality research and cogent analysis that can inform policy. We invite your contributions.

Reducing Life-Threatening Allopurinol Hypersensitivity

Allopurinol is the cornerstone of pharmacologic uratelowering therapy for recurrent gouty arthritis. Although this drug is inexpensive and efficacious, it may cause rare, but life-threatening, cutaneous drug eruptions: the allopurinol hypersensitivity syndrome.1 Mortality rates for individuals experiencing allopurinol hypersensitivity can exceed 30% and long-term morbidity is common.2 In this issue of JAMA Internal Medicine, Yang et al2 demonstrate that in Taiwan, both allopurinol prescribing and hypersensitivity reactions are on the rise. Their findings highlight the value of judicious, guideline-based hyperuricemia management throughout the world. The authors used a retrospective cohort design to investigate the incidence and predictors of allopurinol hypersensitivity among almost every Taiwanese adult during a 6-year period. Using insurance claims, they found that the incidence of allopurinol prescribing and hypersensitivity increased over time, with an overall allopurinol hypersensitivity incidence of 0.4% among new users, 8.3% of whom died from the drug reaction. Hypersensitivity reactions were more likely among new users with chronic kidney disease or cardiovascular disease who received allopurinol for asymptomatic hyperuricemia as opposed to symptomatic gout; these patients represented 49.5% of new user prescriptions by the end of the study period. In the United States, allopurinol hypersensitivity occurs onefourth as often as Yang et al2 found in Taiwan. This lower incidence is in part a matter of genetic epidemiology: the HLA-B*5801 haplotype is strongly associated with allopurinol hypersensitivity and is prevalent in Han Chinese individuals, and the population of Taiwan is 95% Han Chinese.3 Nevertheless, millions of allopurinol prescriptions are dispensed in US ambulatory settings annually. How do we prevent allopurinol hypersensitivity in our ethnically diverse population? Febuxostat, the newer alternative available only as the proprietary formulation, is not associated with the same hypersensitivity reactions as allopurinol. However, transitioning therapy to febuxostat for millions of patients is not cost-effective.4 The findings of Yang et al2 are an important reminder that we should follow the American College of Rheumatology’s guidelines.1 First, begin gout management with lifestyle changes and prescribe urate-lowering therapy only for individuals with frequent gout attacks (>2 per year), tophaceous gout, comorbid stage 2 to 5 chronic kidney disease, or urolithiasis. Allopurinol should not be prescribed for asymptomatic hyperuricemia. Second, all Thai and Han Chinese patients, as well as Korean patients with kidney disease, should be screened for the HLA-B*5801 haplotype prior to allopurinol initiation. If the results of the test are positive or the patients are otherwise at high risk, consider an alternative agent. Finally, start allopurinol therapy at no more than 100 mg/d and titrate the dose slowly.

Searching for Joy in Residency by Listening to Our Patients

phrases or answers while driving to and from hospital and while walking my dog. Once I began to approach communication as a procedure, learning it became more exciting. I came to understand that patients and families are not angry at me, but they are emotionally overwhelmed. By paying enough attention to their emotional distress and trying to explain the complicated situation as simply as possible, I discovered, to my great surprise, that they were tremendously grateful for my communication despite the fact that I kept delivering the worst news in the world. After a year-long palliative care fellowship, my communication skills improved considerably. Now I can conduct difficult communication independently, but I realize that mastering family meetings will be a career-long process. It will require continuous deliberate practice for that skill to grow. That is exactly how I felt at the end of my surgical residency. Based on these experiences in both surgery and palliative care, I have learned 2 lessons: communication, like surgery, is not something trainees are (or are not) good at doing by nature. Second, communication skills, like surgical skills, are something that can be taught, learned, and practiced in a structured way. In sharing these lessons with residents and fellows, I have found a way to continue on the path that both my surgical and palliative medicine mentors so deftly laid out for me.