Availability of Testing for Sexually Transmitted Infections and HIV in U.S. Outpatient Mental Healthcare Settings.

People with mental illnesses experience higher incidence of sexually transmitted illnesses (STIs) and HIV, and estimates show fewer than 50% have received testing. The purpose of this study was to examine the prevalence of STI/HIV testing among United States outpatient mental healthcare service providers. Data from the National Mental Health Services Survey (NMHSS) was used to determine the rates of STI and HIV testing amongst 9,267 outpatient mental healthcare service providers in the U.S. Regression analyses were used to assess whether the likelihood a service provider offered STI or HIV testing was associated with service provider characteristics (facility type, services offered, accepted payments) and state-level incidence of STIs and HIV. We found 7.79% and 6.64% of outpatient mental healthcare service providers provided STI and HIV testing, respectively, with lowest rates in community mental health centers and partial hospitalization facilities. Providing dual-diagnosis for severe mental illness and substance use disorders was an independent predictor of STI testing (aOR = 2.17, [1.72-2.75] and HIV testing (aOR = 2.61, [2.07-3.30]. Higher state-level incidence of STIs and HIV were associated with higher rates of STI testing (ß = 0.28, p = .047) and HIV testing (ß = 0.48, p < .001). Preventing STIs and HIV among patients living with mental illness is a key priority of multiple national initiatives. Despite this, fewer than 10% of outpatient mental healthcare service providers responding to the NMHSS offered STI and HIV testing. Existing service co-delivery models may be one promising method for implementing STI/HIV testing within outpatient mental health settings.

Improving Diabetes Care Through Population Health Innovations and Payments: Lessons from Western Maryland.

BACKGROUND: Global budgets might incentivize healthcare systems to develop population health programs to prevent costly hospitalizations. In response to Maryland's all-payer global budget financing system, University of Pittsburgh Medical Center (UPMC) Western Maryland developed an outpatient care management center called the Center for Clinical Resources (CCR) to support high-risk patients with chronic disease. OBJECTIVE: Evaluate the impact of the CCR on patient-reported, clinical, and resource utilization outcomes for high-risk rural patients with diabetes. DESIGN: Observational cohort study. PARTICIPANTS: One hundred forty-one adult patients with uncontrolled diabetes (HbA1c > 7%) and one or more social needs who were enrolled between 2018 and 2021. INTERVENTIONS: Team-based interventions that provided interdisciplinary care coordination (e.g., diabetes care coordinators), social needs support (e.g., food delivery, benefits assistance), and patient education (e.g., nutritional counseling, peer support). MAIN MEASURES: Patient-reported (e.g., quality of life, self-efficacy), clinical (e.g., HbA1c), and utilization outcomes (e.g., emergency department visits, hospitalizations). KEY RESULTS: Patient-reported outcomes improved significantly at 12 months, including confidence in self-management, quality of life, and patient experience (56% response rate). No significant demographic differences were detected between patients with or without the 12-month survey response. Baseline mean HbA1c was 10.0% and decreased on average by 1.2 percentage points at 6 months, 1.4 points at 12 months, 1.5 points at 18 months, and 0.9 points at 24 and 30 months (P<0.001 at all timepoints). No significant changes were observed in blood pressure, low-density lipoprotein cholesterol, or weight. The annual all-cause hospitalization rate decreased by 11 percentage points (34 to 23%, P=0.01) and diabetes-related emergency department visits also decreased by 11 percentage points (14 to 3%, P=0.002) at 12 months. CONCLUSIONS: CCR participation was associated with improved patient-reported outcomes, glycemic control, and hospital utilization for high-risk patients with diabetes. Payment arrangements like global budgets can support the development and sustainability of innovative diabetes care models.

Missed Screening Mammography Appointments: Patient Sociodemographic Characteristics and Mammography Completion After 1 Year.

OBJECTIVE: Patients who miss screening mammogram appointments without notifying the health care system (no-show) risk care delays. We investigate sociodemographic characteristics of patients who experience screening mammogram no-shows at a community health center and whether and when the missed examinations are completed. METHODS: We included patients with screening mammogram appointments at a community health center between January 1, 2021, and December 31, 2021. Language, race, ethnicity, insurance type, residential ZIP code tabulation area (ZCTA) poverty, appointment outcome (no-show, same-day cancelation, completed), and dates of completed screening mammograms after no-show appointments with ≥1-year follow-up were collected. Multivariable analyses were used to assess associations between patient characteristics and appointment outcomes. RESULTS: Of 6,159 patients, 12.1% (743 of 6,159) experienced no-shows. The no-show group differed from the completed group by language, race and ethnicity, insurance type, and poverty level (all P < .05). Patients with no-shows more often had: primary language other than English (32.0% [238 of 743] versus 26.7% [1,265 of 4,741]), race and ethnicity other than White non-Hispanic (42.3% [314 of 743] versus 33.6% [1,595 of 4,742]), Medicaid or means-tested insurance (62.0% [461 of 743] versus 34.4% [1,629 of 4,742]), and residential ZCTAs with ≥20% poverty (19.5% [145 of 743] versus 14.1% [670 of 4,742]). Independent predictors of no-shows were Black non-Hispanic race and ethnicity (adjusted odds ratio [aOR], 1.52; 95% confidence interval [CI], 1.12-2.07; P = .007), Medicaid or other means-tested insurance (aOR, 2.75; 95% CI, 2.29-3.30; P < .001), and ZCTAs with ≥20% poverty (aOR, 1.76; 95% CI, 1.14-2.72; P = .011). At 1-year follow-up, 40.6% (302 of 743) of patients with no-shows had not completed screening mammogram. DISCUSSION: Screening mammogram no-shows is a health equity issue in which socio-economically disadvantaged and racially and ethnically minoritized patients are more likely to experience missed appointments and continued delays in screening mammogram completion.

The Role of Social Biases, Race, and Condom Use in Willingness to Prescribe HIV Pre-exposure Prophylaxis to MSM: An Experimental, Vignette-Based Study.

INTRODUCTION: Daily antiretroviral pre-exposure prophylaxis (PrEP) is a safe and effective method of preventing HIV. Clinicians' assumptions, biases, and judgments may impede access to PrEP. Specifically, concern that patients will engage in more condomless sex ("risk compensation") has been cited by clinicians as a reason for not prescribing PrEP. METHODS: In this experimental study among medical students, we systematically varied race (White or Black) and condom-use behaviors (continued-use, planned-discontinuation, or continued-nonuse) of a fictional patient (all men with multiple male sex partners). Participants indicated the patients' assumed adherence to PrEP, patients' overall HIV risk, and willingness to prescribe PrEP. Participants completed an implicit association test to detect implicit racism and measures of heterosexism and attitudes toward nonmonogamy, which were examined as moderators of patient race and condom-use effects on participants' assumptions and ultimate willingness to prescribe PrEP. RESULTS: Participants ( N = 600) were most willing to prescribe PrEP to the continued-nonuse patient and least willing to prescribe to the planned-discontinuation patient. No differences were identified based on patient race. The continued-nonuse (vs. continued-use) patient was perceived as less likely to adhere to PrEP, which was associated with lower willingness to prescribe. Negative attitudes toward nonmonogamy exacerbated this effect. No effects of implicit racism or explicit heterosexism were identified. CONCLUSIONS: Participants were least willing to prescribe PrEP to patients who planned to discontinue condom use. Patients seeking PrEP are exhibiting agency over their sexual health, and clinicians should fulfill their role in ensuring access to this primary preventative therapy. Training and curricular reform regarding PrEP are needed.

Patient Sociodemographic Characteristics Associated With Saturday Breast Imaging Clinic Utilization.

OBJECTIVE: To determine patient sociodemographic characteristics associated with breast imaging utilization on Saturdays to inform potential initiatives designed to improve access and reduce disparities in breast cancer care. METHODS: This was an IRB-approved retrospective cross-sectional study. All adult women (aged ≥18 years) who received a screening or diagnostic examination at our breast imaging facility from January 1, 2016 to December 31, 2017 were included. Patient characteristics including age, race, primary language, partnership status, insurance status, and primary care physician status were collected using the electronic medical record. Multiple variable logistic regression analyses were performed to evaluate patient characteristics associated with utilization. RESULTS: Of 53 695 patients who underwent a screening examination and 10 363 patients who underwent a diagnostic examination over our study period, 9.6% (5135/53 695) and 2.0% (209/10 363) of patients obtained their respective examination on a Saturday. In our multiple variable logistic regression analyses, racial/ethnic minorities (odds ratio [OR], 1.5; 95% confidence interval [CI]: 1.4-1.6; P < 0.01) and women who speak English as a second language (OR, 1.1; 95% CI: 1.0-1.3; P = 0.03) were more likely to obtain their screening mammogram on Saturday than their respective counterparts. CONCLUSION: Racial/ethnic minorities and women who speak English as a second language were more likely to obtain their screening mammogram on Saturdays than their respective counterparts. Initiatives to extend availability of breast imaging exams outside of standard business hours increases access for historically underserved groups, which can be used as a tool to reduce breast cancer-related disparities in care.

Opportunities for Radiology Trainee Education Amid the COVID-19 Pandemic: Lessons From an Academic Breast Imaging Program.

The COVID-19 pandemic required restructuring of Radiology trainee education across US institutions. While reduced clinical imaging volume and mandates to maintain physical distancing presented new challenges to traditional medical education during this period, new opportunities developed to support our division in providing high-quality training for residents and fellows. The Accreditation Council for Graduate Medical Education (ACGME) Core Competencies for Diagnostic Radiology helped guide division leadership in restructuring and reframing breast imaging education during this time of drastic change and persistent uncertainty. Here, we reflect on the educational challenges and opportunities faced by our academic breast imaging division during the height of the COVID-19 pandemic across each of the ACGME Core Competencies. We also discuss how systems and processes developed out of necessity during the first peak of the pandemic may continue to support radiology training during phased reopening and beyond.

Pediatric accountable health communities: Insights on needed capabilities and potential solutions.

BACKGROUND: Pediatric accountable health communities (AHCs) are emerging collaborative models that integrate care across health and social service sectors. We aimed to identify needed capabilities and potential solutions for implementing pediatric AHCs. METHODS: We conducted a directed content analysis of responses to a Request for Information (RFI) from the Center for Medicare & Medicaid Innovation on the Integrated Care for Kids Model (n = 1550 pages from 202 respondents). We then interviewed pediatric health policy stakeholders (n = 18) to further investigate responses from the RFI. All responses were coded using a consensual qualitative research approach in 2019. RESULTS: To facilitate service integration, respondents emphasized the need for cross-sector organizational alignment and data sharing. Recommended solutions included designating "Bridge Organizations" to operationalize service integration across sectors and developing integrated data sharing systems. Respondents called for improved validation and collection methods for data relating to school performance, social drivers of health, family well-being, and patient experience. Recommended solutions included aligning health and education data privacy regulations and utilizing metrics with cross-sector relevance. Respondents identified that mechanisms are needed to blend health and social service funding in alternative payment models (APMs). Recommended solutions included guidance on cross-sector care coordination payments, shared savings arrangements, and capitation to maximize spending flexibility. CONCLUSIONS: Pediatric AHCs could provide more integrated, high-value care for children. Respondents highlighted the need for shared infrastructure and cross-sector alignment of measures and financing. IMPLICATIONS: Insights and solutions from this study can inform policymakers planning or implementing innovative, child-centered AHC models. LEVEL OF EVIDENCE: Level V.

Screening Mammography Visits as Opportunities to Engage Smokers With Tobacco Cessation Services and Lung Cancer Screening.

OBJECTIVE: Tobacco use is the leading cause of preventable mortality in the United States. Screening mammography (SM) visits present opportunities for radiology practices to reduce tobacco-related morbidity and mortality. Our study evaluates implementation of a program that provides tobacco cessation service referrals and screens for lung cancer screening (LCS) eligibility among smokers presenting for SM at a community health center. METHODS: In 2018, two sets of questions were added to our SM patient intake questionnaire to assess (1) smoking history and (2) interest in referral to the health center-based tobacco cessation program for mailed information, telephone-based consultation, and in-person counseling. Primary outcomes were proportion of current smokers who requested a referral and of all smokers who were LCS-eligible. Bivariate logistic regression analyses compared sociodemographic characteristics of smokers who requested versus declined a referral. RESULTS: Of the 89.3% (1,907 of 2,136) who responded, 10.5% (201 of 1,907) were current and 29.1% (555 of 1,907) were former smokers. Of current smokers, 26.4% (53 of 201) requested referrals: mailed information by 23.9% (48 of 201), in-person counseling by 9% (18 of 201), and telephone-based consultation by 7.5% (15 of 201). No sociodemographic predictors for referral requests were identified. Of all smokers, 9.3% (70 of 756) were eligible for LCS, of which 31.4% (22 of 70) were up to date. CONCLUSION: One in ten women who underwent SM at our community health center were current smokers, of which one-quarter requested tobacco cessation referrals. Among LCS-eligible smokers, one-third were up to date. SM presents opportunities for radiology practices to advance population health goals such as tobacco cessation and LCS.

Tapering off long-term methadone: A case study.

Opioid tapering may be necessary for patients on long-term opioids. Here, the authors presented a patient who had uncontrolled chronic musculoskeletal pain while on chronic methadone. Upon methadone tapering, the patient had been taking methadone for longer than six years and had severe methadone-related adverse effects. Using multidisciplinary interventions of patient education and counseling, physical interventions, and nonopioid medications, patient's methadone was discontinued after longer than one year tapering with relatively good pain control. The tapering process highlights the importance of pain management during opioid tapering using multidisciplinary interventions to prevent and treat opioid withdrawal and pain relapses.

Management of patients with pain and severe side effects while on intrathecal morphine therapy: A case study.

BACKGROUND AND AIMS: The use of intrathecal morphine therapy has been increasing. Intrathecal morphine therapy is deemed the last resort for patients with intractable chronic non-cancer pain (CNCP) who failed other treatments including surgery and pharmaceutical interventions. However, effective treatments for patients with CNCP who "failed" this last resort because of severe side effects and lack of optimal pain control remain unclear. METHODS AND RESULTS: Here we report two successfully managed patients (Ms. S and Mr. T) who had intractable pain and significant complications years after the start of intrathecal morphine therapy. The two patients had intrathecal morphine pump implantation due to chronic consistent pain and multiple failed surgical operations in the spine. Years after morphine pump implantation, both patients had significant chronic pain and compromised function for activities of daily living. Additionally, Ms. S also had four episodes of small bowel obstruction while Mr. T was diagnosed with end stage severe "dementia". The successful management of these two patients included the simultaneous multidisciplinary approach for pain management, opioids tapering and discontinuation. CONCLUSION: The case study indicates that for patients who fail to respond to intrathecal morphine pump therapy due to side effects and lack of optimal pain control, the simultaneous multidisciplinary pain management approach and opioids tapering seem appropriate.