Transitions of care between jail-based medications for opioid use disorder and ongoing treatment in the community: A retrospective cohort study.

BACKGROUND: Offering medications for opioid use disorder (MOUD) in carceral settings significantly reduces overdose. However, it is unknown to what extent individuals in jails continue MOUD once they leave incarceration. We aimed to assess the relationship between in-jail MOUD and MOUD continuity in the month following release. METHODS: We conducted a retrospective cohort study of linked NYC jail-based electronic health records and community Medicaid OUD treatment claims for individuals with OUD discharged from jail between 2011 and 2017. We compared receipt of MOUD within 30 days of release, among those with and without MOUD at release from jail. We tested for effect modification based on MOUD receipt prior to incarceration and assessed factors associated with treatment discontinuation. RESULTS: Of 28,298 eligible incarcerations, 52.8 % received MOUD at release. 30 % of incarcerations with MOUD at release received community-based MOUD within 30 days, compared to 7 % of incarcerations without MOUD (Risk Ratio: 2.62 (2.44-2.82)). Most (69 %) with MOUD claims prior to incarceration who received in-jail MOUD continued treatment in the community, compared to 9 % of those without prior MOUD. Those who received methadone (vs. buprenorphine), were younger, Non-Hispanic Black and with no history of MOUD were less likely to continue MOUD following release. CONCLUSIONS: MOUD maintenance in jail is strongly associated with MOUD continuity upon release. Still, findings highlight a gap in treatment continuity upon-reentry, especially among those who initiate MOUD in jail. In the wake of worsening overdose deaths and troubling disparities, improving MOUD continuity among this population remains an urgent priority.

Impact of jail-based methadone or buprenorphine treatment on non-fatal opioid overdose after incarceration.

BACKGROUND: Non-fatal overdose is a leading predictor of subsequent fatal overdose. For individuals who are incarcerated, the risk of experiencing an overdose is highest when transitioning from a correctional setting to the community. We assessed if enrollment in jail-based medications for opioid use disorder (MOUD) is associated with lower risk of non-fatal opioid overdoses after jail release among individuals with opioid use disorder (OUD). METHODS: This was a retrospective, observational cohort study of adults with OUD who were incarcerated in New York City jails and received MOUD or did not receive any MOUD (out-of-treatment) within the last three days before release to the community in 2011-2017. The outcome was the first non-fatal opioid overdose emergency department (ED) visit within 1 year of jail release during 2011-2017. Covariates included demographic, clinical, incarceration-related, and other characteristics. We performed multivariable cause-specific Cox proportional hazards regression analysis to compare the risk of non-fatal opioid overdose ED visits within 1 year after jail release between groups. RESULTS: MOUD group included 8660 individuals with 17,119 incarcerations; out-of-treatment group included 10,163 individuals with 14,263 incarcerations. Controlling for covariates and accounting for competing risks, in-jail MOUD was associated with lower non-fatal opioid overdose risk within 14 days after jail release (adjusted HR=0.49, 95% confidence interval=0.33-0.74). We found no significant differences 15-28, 29-56, or 57-365 days post-release. CONCLUSION: MOUD group had lower risk of non-fatal opioid overdose immediately after jail release. Wider implementation of MOUD in US jails could potentially reduce post-release overdoses, ED utilization, and associated healthcare costs.

Jail-based medication for opioid use disorder and patterns of reincarceration and acute care use after release: A sequence analysis.

BACKGROUND: Treatment with methadone and buprenorphine medications for opioid use disorder (MOUD) during incarceration may lead to better community re-entry, but evidence on these relationships have been mixed. We aimed to identify community re-entry patterns and examine the association between in-jail MOUD and a pattern of successful reentry defined by rare occurrence of reincarceration and preventable healthcare utilization. METHODS: Data came from a retrospective, observational cohort study of 6066 adults with opioid use disorder who were incarcerated in New York City jails and released to the community during 2011-14. An outcome was community re-entry patterns identified by sequence analysis of 3-year post-release reincarceration, emergency department visits, and hospitalizations. An exposure was receipt of in-jail MOUD versus out-of-treatment (42 % vs. 58 %) for the last 3 days before discharge. The study accounted for differences in baseline demographic, clinical, behavioral, housing, and criminal legal characteristics between in-jail MOUD and out-of-treatment groups via propensity score matching. RESULTS: This study identified five re-entry patterns: stability (64 %), hospitalization (23 %), delayed reincarceration (7 %), immediate reincarceration (4 %), and continuous incarceration (2 %). After addressing confounding, 64 % and 57 % followed the stability pattern among MOUD and out-of-treatment groups who were released from jail in 2011, respectively. In 2012-14, the prevalence of following the stability pattern increased year-by-year while a consistently higher prevalence was observed among those with in-jail MOUD. CONCLUSIONS: Sequence analysis helped define post-release stability based on health and criminal legal system involvement. Receipt of in-jail MOUD was associated with a marker of successful community re-entry.

Long travel times from health center to hospital reduce caesarean section access: a study from Kirehe District, Rwanda.

Introduction: timely access to safe cesarean section (c-section) delivery can save the lives of mothers and neonates. This paper explores how distance affects c-section access in rural sub-Saharan Africa, where women in labor present to health centers before being referred to district hospitals for surgical care. Methods: this study included all adult women delivering via c-section between April 2017 and March 2018 in Kirehe District, Rwanda. We assessed the association between travel times and village-level c-section rates. Results: the estimated travel time from home-to-health center was 26 minutes (IQR: 13, 41) and from health center-to-hospital was 43 minutes (IQR: 2, 59). There was no significant association between travel time from home-to-health center and c-section rates (RR=1.01, p=0.42), but the association was significant for health center-to-hospital travel times (RR=0.96, p=0.01); for every 15-minute increase in travel time, there was a 4% decrease in c-sections for a health center catchment area. Conclusion: in the context of decentralized health services, minimizing health center to hospital referral barriers is of utmost importance for improving c-section access in rural sub-Saharan Africa.

Association between jail-based methadone or buprenorphine treatment for opioid use disorder and overdose mortality after release from New York City jails 2011-17.

BACKGROUND AND AIMS: Opioid overdose is a leading cause of death during the immediate time after release from jail or prison. Most jails in the United States do not provide methadone and buprenorphine treatment for opioid use disorder (MOUD), and research in estimating its impact in jail settings is limited. We aimed to test the hypothesis that in-jail MOUD is associated with lower overdose mortality risk post-release. DESIGN, SETTING AND PARTICIPANTS: Retrospective, observational cohort study of 15 797 adults with opioid use disorder who were released from New York City jails to the community in 2011-2017. They experienced 31 382 incarcerations and were followed up to 1 year. MEASUREMENTS: The primary outcomes were death caused by accidental drug poisoning and all-cause death. The exposure was receipt of MOUD (17 119 events) versus out-of-treatment (14 263 events) during the last 3 days before community re-entry. Covariates included demographic, clinical, behavioral, housing, health-care utilization and legal characteristics variables. We performed a multivariable, mixed-effect Cox regression analysis to test association between in-jail MOUD and deaths. FINDINGS: The majority were male (82%) and their average age was 42 years. Receiving MOUD was associated with misdemeanor charges, being female, injection drug use and homelessness. During 1 year post-release, 111 overdose deaths occurred and crude death rates were 0.49 and 0.83 per 100 person-years for in-jail MOUD and out-of-treatment groups, respectively. Accounting for confounding and random effects, in-jail MOUD was associated with lower overdose mortality risk [adjusted hazard ratio (aHR) = 0.20, 95% confidence interval (CI) = 0.08-0.46] and all-cause mortality risk (aHR = 0.22, 95% CI = 0.11-0.42) for the first month post-release. CONCLUSIONS: Methadone and buprenorphine treatment for opioid use disorder during incarceration was associated with an 80% reduction in overdose mortality risk for the first month post-release.

The Effect and Feasibility of mHealth-Supported Surgical Site Infection Diagnosis by Community Health Workers After Cesarean Section in Rural Rwanda: Randomized Controlled Trial.

BACKGROUND: The development of a surgical site infection (SSI) after cesarean section (c-section) is a significant cause of morbidity and mortality in low- and middle-income countries, including Rwanda. Rwanda relies on a robust community health worker (CHW)-led, home-based paradigm for delivering follow-up care for women after childbirth. However, this program does not currently include postoperative care for women after c-section, such as SSI screenings. OBJECTIVE: This trial assesses whether CHW's use of a mobile health (mHealth)-facilitated checklist administered in person or via phone call improved rates of return to care among women who develop an SSI following c-section at a rural Rwandan district hospital. A secondary objective was to assess the feasibility of implementing the CHW-led mHealth intervention in this rural district. METHODS: A total of 1025 women aged ≥18 years who underwent a c-section between November 2017 and September 2018 at Kirehe District Hospital were randomized into the three following postoperative care arms: (1) home visit intervention (n=335, 32.7%), (2) phone call intervention (n=334, 32.6%), and (3) standard of care (n=356, 34.7%). A CHW-led, mHealth-supported SSI diagnostic protocol was delivered in the two intervention arms, while patients in the standard of care arm were instructed to adhere to routine health center follow-up. We assessed intervention completion in each intervention arm and used logistic regression to assess the odds of returning to care. RESULTS: The majority of women in Arm 1 (n=295, 88.1%) and Arm 2 (n=226, 67.7%) returned to care and were assessed for an SSI at their local health clinic. There were no significant differences in the rates of returning to clinic within 30 days (P=.21), with high rates found consistently across all three arms (Arm 1: 99.7%, Arm 2: 98.4%, and Arm 3: 99.7%, respectively). CONCLUSIONS: Home-based post-c-section follow-up is feasible in rural Africa when performed by mHealth-supported CHWs. In this study, we found no difference in return to care rates between the intervention arms and standard of care. However, given our previous study findings describing the significant patient-incurred financial burden posed by traveling to a health center, we believe this intervention has the potential to reduce this burden by limiting patient travel to the health center when an SSI is ruled out at home. Further studies are needed (1) to determine the acceptability of this intervention by CHWs and patients as a new standard of care after c-section and (2) to assess whether an app supplementing the mHealth screening checklist with image-based machine learning could improve CHW diagnostic accuracy. TRIAL REGISTRATION: ClinicalTrials.gov NCT03311399; https://clinicaltrials.gov/ct2/show/NCT03311399.

Telemedicine for Surgical Site Infection Diagnosis in Rural Rwanda: Concordance and Accuracy of Image Reviews.

BACKGROUND: In rural Africa where access to medical personnel is limited, telemedicine can be leveraged to empower community health workers (CHWs) to support effective postpartum home-based care after cesarean section (c-section). As a first step toward telemedicine, we assessed the sensitivity, specificity, and interrater reliability of image-based diagnosis of surgical site infections (SSIs) among women delivering via c-section at a rural Rwandan Hospital. METHODS: Women ≥18 years who underwent c-section from March to October 2017 at Kirehe District Hospital (KDH) were enrolled. On postoperative day 10 at KDH, participants underwent a physical examination by a general practitioner, who provided a diagnosis of SSI or no SSI. Trained CHWs photographed patients' incisions and the collected images were shown to six physicians, who upon review, assigned one of the following diagnoses to each image: definite SSI, suspected SSI, suspected no SSI, and definite no SSI, which were compared with the diagnoses based on physical exam. We report the sensitivity and specificity and assessed reviewer agreement using Gwet's AC1. RESULTS: 569 images were included, with 61 women (10.7%) diagnosed with an SSI. Of the 3414 image-reviews, 49 (1.4%) could not be assigned diagnoses due to image quality. The median sensitivity and specificity were 0.83 and 0.69, respectively. The Gwet's AC1 estimate for binary classification was 0.46. CONCLUSIONS: We demonstrate decent accuracy but only moderate consistency for photograph-based SSI diagnosis. Strategies to improve overall agreement include providing clinical information to accompany photographs, providing a baseline photograph for comparison, and implementing photograph-taking processes aimed at improving image quality.

Association of Maternal Nativity Status and Race/Ethnicity on Emergency Department Utilization Among Children in Vulnerable Families.

OBJECTIVES: We aimed to determine the role of mothers' nativity and race/ethnicity on their children's emergency department utilization. METHODS: Data from the Fragile Families and Child Wellbeing Study was used for the analyses. Descriptive and regression analyses were conducted to compare use of ED services between children of foreign-born versus US-born mothers within different racial groups. RESULTS: The sample in this analysis contained 3426 mother-child pairs, of which 14.2% were foreign-born mothers. Adjusting for mother's race, education, and marital status, child's insurance coverage, and caregiver's perception of child's health, children of foreign-born mothers were less likely to use ED services compared with those born to US-born mothers (risk ratio [RR], 0.71 [0.54-0.94]). Emergency department utilization was lower among children of Hispanic, foreign-born mothers (RR, 0.67 [0.46-0.96]) and among children of non-Hispanic Asian or other race, foreign-born mothers (RR, 0.32 [0.14-0.74]) when compared with children of their US-born counterparts in the respective race. CONCLUSIONS: Maternal nativity status and race influence child's use of emergency department services. Future research should explore the intersection of parental nativity, immigrant documentation status, and citizenship status and how that may influence children's health care usage.

Presentation of Pediatric Unintentional Injuries at Rural Hospitals in Rwanda: A Retrospective Study.

Background: Injuries are a leading cause of mortality among children globally, with children in low- and middle-income countries more likely to die if injured compared to children in high-income countries. Timely and high-quality care are essential to reduce injury-related morbidity and mortality. Objectives: This study describes patterns, management, and outcomes of children 0-15 years presenting with unintentional injuries at three district hospitals in rural Rwanda between January 1 and December 31, 2017. Methods: Using a retrospective cross-sectional study design, we assessed the demographic and clinical characteristics, care provided, and outcomes of the children using data extracted from patient medical charts. We describe the patient population using frequencies and proportions as well as median and interquartile ranges. Findings: Of the 449 injured children who sought care at the three rural district hospitals, 66.2% (n = 297) were boys. The main causes of injury were falls (n = 261, 58.1%), burns (n = 101, 22.5%), and road traffic injuries (n = 67, 14.9%). Burns were the most common injury among children aged 0-5 years while falls were the leading injury type among the 5-15 years age group. Vital signs were inconsistently completed ranging between 23.8-89.1% of vital sign items. Of the injured children, 37.0% (n = 166) received surgery at the district hospital, general practitioners performed 80.9% (n = 114) of surgeries, 87.4% (n = 145) of operated patients received no anesthesia, and 69.3% (n = 311) were admitted to the district hospital, while 2.7% (n = 12) were transferred to tertiary facilities for higher-level care. Conclusions: The presentation of child injuries-namely falls, burns, and road traffic accidents-is similar to what has been reported in other sub-Saharan African countries. However, more needs to be done to improve the completion and documentation of vital signs and increase availability of surgical specialists. Finally, targeted strategies to prevent burns and motorcycle-related injuries are recommended prevention interventions for this rural population.

Diagnosing Post-Cesarean Surgical Site Infections in Rural Rwanda: Development, Validation, and Field Testing of a Screening Algorithm for Use by Community Health Workers.

Background: We aimed to develop and validate a screening algorithm to assist community health workers (CHWs) in identifying surgical site infections (SSIs) after cesarean section (c-section) in rural Africa. Methods: Patients were adult women who underwent c-section at a Rwandan rural district hospital between March and October 2017. A CHW administered a nine-item clinical questionnaire 10 ± 3 days post-operatively. Independently, a general practitioner (GP) administered the same questionnaire and assessed SSI presence by physical examination. The GP's SSI diagnosis was used as the gold standard. Using a simplified Classification and Regression Tree analysis, we identified a subset of screening questions with maximum sensitivity for the GP and CHW and evaluated the subset's sensitivity and specificity in a validation dataset. Then, we compared the subset's results when implemented in the community by CHWs with health center-reported SSI. Results: Of the 596 women enrolled, 525 (88.1%) completed the clinical questionnaire. The combination of questions concerning fever, pain, and discolored drainage maximized sensitivity for both the GPs (sensitivity = 96.8%; specificity = 85.6%) and CHWs (sensitivity = 87.1%; specificity = 73.8%). In the validation dataset, this subset had sensitivity of 95.2% and specificity of 83.3% for the GP-administered questions and sensitivity of 76.2% and specificity of 81.4% for the CHW-administered questions. In the community screening, the overall percent agreement between CHW and health center diagnoses was 81.1% (95% confidence interval: 77.2%-84.6%). Conclusions: We identified a subset of questions that had good predictive features for SSI, but its sensitivity was lower when administered by CHWs in a clinical setting, and it performed poorly in the community. Methods to improve diagnostic ability, including training or telemedicine, must be explored.

Perioperative Management and Outcomes After Cesarean Section-A Cross-Sectional Study From Rural Rwanda.

BACKGROUND: Cesarean sections (c-sections), the most common surgical procedures performed worldwide, are essential in reducing maternal and neonatal deaths. There is a paucity of research studies on c-section care and outcomes in rural African settings. The objective of this study was to describe demographic characteristics, clinical management, and maternal and neonatal outcomes among women receiving c-sections at Kirehe District Hospital (KDH) in rural Rwanda. METHODS: This retrospective cohort study included all women aged ≥ 18 y residing in KDH catchment area who delivered by c-section at KDH between April 1 and September 30, 2017. Demographic and clinical characteristics of these women and their newborns were collected using patient interviews and medical chart extraction. Descriptive analyses were performed, and frequency and percentages are reported. RESULTS: Of the 621 women included in the study, 45.7% (n = 284) were aged 25-34 y; 42.2% (n = 262) were married; 67.5% (n = 419) had primary education; and 75.7% (n = 470) were farmers by occupation. Burundian refugees living in the nearby Mahama Refugee Camp comprised 13.7% (n = 85) of the study population. The most common indication for c-section was having undergone a c-section previously (31.9%, n = 198), followed by acute fetal distress (30.8%, n = 191). Among those with previous c-section as the sole indication for surgery, 85.4% presented as either urgent or emergent cases. Postoperatively, 67.7% spent less than 4 d at the hospital and 96.1% had no postoperative complications before discharge. Approximately 10% (59/572) of neonates were admitted to the neonatal unit, with the most common reason being neonatal infection (59.6%, n = 31). CONCLUSIONS: Our study found that previous delivery via c-section was the primary indication for c-section and that most of these cases were emergent or urgent on presentation. This study highlights the need for further research to explore the feasibility, safety, and appropriateness of vaginal birth after cesarean in rural district hospitals in sub-Saharan Africa.

Adoption of Telehealth: Remote Biometric Monitoring Among Peritoneal Dialysis Patients in the United States.

We examined participant uptake and utilization of remote monitoring devices, and the relationship between remote biometric monitoring (RBM) of weight (Wt) and blood pressure (BP) with self-monitoring requirements. Participants on peritoneal dialysis (PD) (n = 269) participated in a Telehealth pilot study of which 253 used remote monitoring of BP and 255 for Wt. Blood pressure and Wt readings were transmitted in real time to a Telehealth call center, which were then forwarded to the PD nurses for real-time review. Uptake of RBM was substantial, with 89.7% accepting RBM, generating 74,266 BP and 52,880 Wt measurements over the study period. We found no significant correlates of RBM uptake with regard to gender, marital, educational, socio-economic or employment status, or baseline experience with computers; frequency of use of BP RBM by Black participants was less than non-Black participants, as was Wt RBM, and participants over 55 years old were more likely to use the Wt RBM than their younger counterparts. Having any review of the breach by a nurse was associated with reduced odds of a subsequent BP breach after adjusting for sex, age, and race. Remote biometric monitoring was associated with adherence to self-monitoring BP and Wt requirements associated with PD. Remote biometric monitoring was feasible, allowing for increased communication between patient and PD clinical staff with real-time patient data for providers to act on to potentially improve adherence and outcomes.

Satisfaction and Improvements in Peritoneal Dialysis Outcomes Associated with Telehealth.

BACKGROUND AND SIGNIFICANCE: End stage renal disease (ESRD) affects approximately 660,000 persons in the US each year, representing a significant financial burden to the health care system and affected individuals. Telehealth approaches to care offer an important means of reducing costs as well as increasing autonomy for patients. Understanding patient satisfaction with telehealth provides a key towards eventual scalability. MATERIALS AND METHODS: Quarterly surveys were conducted to characterize satisfaction with remote biometric monitoring (RBM) for blood pressure, weight, glucose and peritoneal dialysis (PD)-specific educational online videos for ESRD patients using PD. RESULTS: Of 300 participants, 67% participated in the surveys and provided baseline and at least one follow-up assessment. The majority were 45 to 64 years of age (50.5%), Black (64.5%), married or living with significant other (52.0%), and had more than a high school degree (73.0%). RBM was associated with perceived autonomy and confidence in health care activities and decreased negative perceptions of PD care and ESRD. The majority of participants (80.1%) indicated that they were satisfied or completely satisfied with the system. Participants found that the interface increased confidence, reduced frustration, and related perceptions were significantly and positively altered (p<0.05) for each of the separate telehealth components. Educational videos were well utilized with nearly half of the participants (42.5%) reporting that they watched at least one of the videos, and the majority reporting that the videos seen had an overall positive impact on health. DISCUSSION AND CONCLUSIONS: Supplementing PD with telehealth has the potential to have a positive impact on patient perceptions of PD care and consequently improve clinical outcomes.