Asynchronous Versus Synchronous Screening for Depression and Suicidality in a Primary Health Care System: Quality Improvement Study.

Background: Despite being a debilitating, costly, and potentially life-threatening condition, depression is often underdiagnosed and undertreated. Previsit Patient Health Questionnaire-9 (PHQ-9) may help primary care health systems identify symptoms of severe depression and prevent suicide through early intervention. Little is known about the impact of previsit web-based PHQ-9 on patient care and safety. Objective: We aimed to investigate differences among patient characteristics and provider clinical responses for patients who complete a web-based (asynchronous) versus in-clinic (synchronous) PHQ-9. Methods: This quality improvement study was conducted at 33 clinic sites across 2 health systems in Northern California from November 1, 2020, to May 31, 2021, and evaluated 1683 (0.9% of total PHQs completed) records of patients endorsing thoughts that they would be better off dead or of self-harm (question 9 in the PHQ-9) following the implementation of a depression screening program that included automated electronic previsit PHQ-9 distribution. Patient demographics and providers' clinical response (suicide risk assessment, triage nurse connection, medication management, electronic consultation with psychiatrist, and referral to social worker or psychiatrist) were compared for patients with asynchronous versus synchronous PHQ-9 completion. Results: Of the 1683 patients (female: n=1071, 63.7%; non-Hispanic: n=1293, 76.8%; White: n=831, 49.4%), Hispanic and Latino patients were 40% less likely to complete a PHQ-9 asynchronously (odds ratio [OR] 0.6, 95% CI 0.45-0.8; P<.001). Patients with Medicare insurance were 36% (OR 0.64, 95% CI 0.51-0.79) less likely to complete a PHQ-9 asynchronously than patients with private insurance. Those with moderate to severe depression were 1.61 times more likely (95% CI 1.21-2.15; P=.001) to complete a PHQ-9 asynchronously than those with no or mild symptoms. Patients who completed a PHQ-9 asynchronously were twice as likely to complete a Columbia-Suicide Severity Rating Scale (OR 2.41, 95% CI 1.89-3.06; P<.001) and 77% less likely to receive a referral to psychiatry (OR 0.23, 95% CI 0.16-0.34; P<.001). Those who endorsed question 9 "more than half the days" (OR 1.62, 95% CI 1.06-2.48) and "nearly every day" (OR 2.38, 95% CI 1.38-4.12) were more likely to receive a referral to psychiatry than those who endorsed question 9 "several days" (P=.002). Conclusions: Shifting depression screening from in-clinic to previsit led to a dramatic increase in PHQ-9 completion without sacrificing patient safety. Asynchronous PHQ-9 can decrease workload on frontline clinical team members, increase patient self-reporting, and elicit more intentional clinical responses from providers. Observed disparities will inform future improvement efforts.

Methamphetamine-associated heart failure: a systematic review of observational studies.

OBJECTIVE: To conduct a systematic review of observational studies on methamphetamine-associated heart failure (MethHF) . METHODS: Six databases were searched for original publications on the topic. Title/abstract and included full-text publications were reviewed in duplicate. Data extraction and critical appraisal for risk of bias were performed in duplicate. RESULTS: Twenty-one studies are included in the final analysis. Results could not be combined because of heterogeneity in study design, population, comparator, and outcome assessment. Overall risk of bias is moderate due to the presence of confounders, selection bias and poor matching; overall certainty in the evidence is very low. MethHF is increasing in prevalence, affects diverse racial/ethnic/sociodemographic groups with a male predominance; up to 44% have preserved left-ventricular ejection fraction. MethHF is associated with significant morbidity including worse heart failure symptoms compared with non-methamphetamine related heart failure. Female sex, methamphetamine abstinence and guideline-directed heart failure therapy are associated with improved outcomes. Chamber dimensions on echocardiography and fibrosis on biopsy predict the extent of recovery after abstinence. CONCLUSIONS: The increasing prevalence of MethHF with associated morbidity underscores the urgent need for well designed prospective studies of people who use methamphetamine to accurately assess the epidemiology, clinical features, disease trajectory and outcomes of MethHF. Methamphetamine abstinence is an integral part of MethHF treatment; increased availability of effective non-pharmacological interventions for treatment of methamphetamine addiction is an essential first step. Availability of effective pharmacological treatment for methamphetamine addiction will further support MethHF treatment. Using harm reduction principles in an integrated addiction/HF treatment programme will bolster efforts to stem the increasing tide of MethHF.

The economic burden of noncommunicable diseases and mental health conditions: results for Costa Rica, Jamaica, and Peru.

OBJECTIVE: We extend the EPIC model of the World Health Organization (WHO) and apply it to analyze the macroeconomic impact of noncommunicable diseases (NCDs) and mental health conditions in Costa Rica, Jamaica, and Peru. METHODS: The EPIC model quantifies the impact of NCDs and mental health conditions on aggregate output solely through the effect of chronic conditions on labor supply due to mortality. In contrast, the expanded EPIC-H Plus framework also incorporates reductions in effective labor supply due to morbidity and negative effects of health expenditure on output via the diversion of productive savings and reduced capital accumulation. We apply this methodology to Costa Rica, Jamaica, and Peru and estimate gross domestic product (GDP) output lost due to four leading NCDs (cardiovascular disease, cancer, chronic respiratory disease, and diabetes) and mental health conditions in these countries from 2015 to 2030. We also estimate losses from all NCDs and mental health conditions combined. RESULTS: Overall, our results show total losses associated with all NCDs and mental health conditions over the period 2015-2030 of US$ 81.96 billion (2015 US$) for Costa Rica, US$ 18.45 billion for Jamaica, and US$ 477.33 billion for Peru. Moderate variation exists in the magnitude of the burdens of diseases for the three countries. In Costa Rica and Peru, respiratory disease and mental health conditions are two leading contributors to lost output, while in Jamaica, cardiovascular disease alone accounts for 20.8% of the total loss, followed by cancer. CONCLUSIONS: These results indicate that the economic impact of NCDs and mental health conditions is substantial and that interventions to reduce the prevalence of chronic conditions in countries of Latin America and the Caribbean are likely to be highly cost-beneficial.

The economic burden of noncommunicable diseases and mental health conditions: results for Costa Rica, Jamaica, and Peru / La carga económica de las enfermedades no transmisibles y la enfermedad mental: resultados para Costa Rica, Jamaica y Perú / A carga econômica das doenças não transmissíveis e condições de saúde mental: resultados para a Costa Rica, Jamaica e Peru

ABSTRACT Objective We extend the EPIC model of the World Health Organization (WHO) and apply it to analyze the macroeconomic impact of noncommunicable diseases (NCDs) and mental health conditions in Costa Rica, Jamaica, and Peru. Methods The EPIC model quantifies the impact of NCDs and mental health conditions on aggregate output solely through the effect of chronic conditions on labor supply due to mortality. In contrast, the expanded EPIC-H Plus framework also incorporates reductions in effective labor supply due to morbidity and negative effects of health expenditure on output via the diversion of productive savings and reduced capital accumulation. We apply this methodology to Costa Rica, Jamaica, and Peru and estimate gross domestic product (GDP) output lost due to four leading NCDs (cardiovascular disease, cancer, chronic respiratory disease, and diabetes) and mental health conditions in these countries from 2015 to 2030. We also estimate losses from all NCDs and mental health conditions combined. Results Overall, our results show total losses associated with all NCDs and mental health conditions over the period 2015-2030 of US$ 81.96 billion (2015 US$) for Costa Rica, US$ 18.45 billion for Jamaica, and US$ 477.33 billion for Peru. Moderate variation exists in the magnitude of the burdens of diseases for the three countries. In Costa Rica and Peru, respiratory disease and mental health conditions are two leading contributors to lost output, while in Jamaica, cardiovascular disease alone accounts for 20.8% of the total loss, followed by cancer. Conclusions These results indicate that the economic impact of NCDs and mental health conditions is substantial and that interventions to reduce the prevalence of chronic conditions in countries of Latin America and the Caribbean are likely to be highly cost-beneficial.

RESUMEN Objetivo Ampliamos el modelo EPIC de la Organización Mundial de la Salud y lo aplicamos para analizar el impacto macroeconómico de las enfermedades no transmisibles y la enfermedad mental en Costa Rica, Jamaica y Perú. Métodos El modelo EPIC cuantifica el impacto de las enfermedades no transmisibles y la enfermedad mental en la producción agregada únicamente a través del efecto que las enfermedades crónicas producen sobre la oferta de trabajo debido a la mortalidad que estas causan. En cambio, el marco ampliado EPIC-H Plus también incorpora reducciones en la oferta efectiva de trabajo debido a la morbilidad y los efectos negativos del gasto en salud sobre la producción a través del desvío del ahorro productivo y la reducción de la acumulación de capital. Aplicamos esta metodología a Costa Rica, Jamaica y Perú y estimamos la pérdida en términos de producto interno bruto debida a cuatro enfermedades no transmisibles (enfermedades cardiovasculares, cáncer, enfermedad respiratoria crónica y diabetes) y a la enfermedad mental en estos países desde 2015 a 2030. También estimamos las pérdidas de todas las enfermedades no transmisibles y la enfermedad mental combinadas. Resultados En general, nuestros resultados muestran pérdidas totales asociadas con todas las enfermedades no transmisibles y la enfermedad mental durante el período 2015-2030 de USD 81,96 mil millones (en dólares de 2015) para Costa Rica, USD 18,45 mil millones para Jamaica y USD 477,33 mil millones para Perú. Existe una variación moderada en la magnitud de la carga de las enfermedades para los tres países. En Costa Rica y Perú, las afecciones respiratorias y la enfermedad mental son los dos factores principales que contribuyen a la pérdida de producción, mientras que en Jamaica la enfermedad cardiovascular sola representa el 20,8% de la pérdida total, seguida por el cáncer. Conclusiones Estos resultados indican que el impacto económico de las enfermedades no transmisibles y la enfermedad mental es considerable y que las intervenciones para reducir la prevalencia de enfermedades crónicas en América Latina y el Caribe probablemente sean muy beneficiosas en relación al costo.

RESUMO Objetivo Estendemos o modelo EPIC da Organização Mundial da Saúde e aplicamos para analisar o impacto macroeconômico das doenças não transmissíveis (DNT) e as condições de saúde mental na Costa Rica, Jamaica e Peru. Métodos O modelo EPIC quantifica o impacto das DNT e condições de saúde mental na produção agregada unicamente através do efeito de condições crônicas na oferta de trabalho devido à mortalidade. Em contrapartida, a estrutura ampliada EPIC-H Plus também incorpora reduções na oferta de trabalho efetiva devido à morbidade e aos efeitos negativos das despesas de saúde na produção através do desvio de poupanças produtivas e redução da acumulação de capital. Aplicamos essa metodologia à Costa Rica, Jamaica e Peru e estimamos a perda de produto interno bruto devido a quatro DNT (doenças cardiovasculares, câncer, doenças respiratórias crônicas e diabetes) e condições de saúde mental nesses países de 2015 a 2030. Também estimamos as perdas de todas as DNT e condições de saúde mental combinadas. Resultados No geral, nossos resultados mostram perdas totais associadas a todas as DNT e condições de saúde mental no período 2015-2030 de USD 81,96 bilhões (USD de 2015) para a Costa Rica, USD 18,45 bilhões para a Jamaica e USD 477,33 bilhões para o Peru. Existe variação moderada na magnitude da carga das doenças para os três países. Na Costa Rica e no Peru, as doenças respiratórias e as condições de saúde mental são dois principais contribuintes para a perda de produção, enquanto na Jamaica, a doença cardiovascular sozinha representa 20,8% da perda total, seguida de câncer. Conclusões Esses resultados indicam que o impacto econômico das doenças não transmissíveis e as condições de saúde mental são substanciais e que as intervenções para reduzir a prevalência de condições crônicas em países da América Latina e do Caribe são benéficos em relação ao custo.

Do gifts increase consent to home-based HIV testing? A difference-in-differences study in rural KwaZulu-Natal, South Africa.

Background: Despite the importance of HIV testing for controlling the HIV epidemic, testing rates remain low. Efforts to scale up testing coverage and frequency in hard-to-reach and at-risk populations commonly focus on home-based HIV testing. This study evaluates the effect of a gift (a US$5 food voucher for families) on consent rates for home-based HIV testing. Methods: We use data on 18 478 individuals (6 418 men and 12 060 women) who were successfully contacted to participate in the 2009 and 2010 population-based HIV surveillance carried out by the Wellcome Trust's Africa Health Research Institute in rural KwaZulu-Natal, South Africa. Of 18 478 potential participants contacted in both years, 35% (6 518) consented to test in 2009, and 41% (7 533) consented to test in 2010. Our quasi-experimental difference-in-differences approach controls for unobserved confounding in estimating the causal effect of the intervention on HIV-testing consent rates. Results: Allocation of the gift to a family in 2010 increased the probability of family members consenting to test in the same year by 25 percentage points [95% confidence interval (CI) 21-30 percentage points; P < 0.001]. The intervention effect persisted, slightly attenuated, in the year following the intervention (2011). Conclusions: In HIV hyperendemic settings, a gift can be highly effective at increasing consent rates for home-based HIV testing. Given the importance of HIV testing for treatment uptake and individual health, as well as for HIV treatment-as-prevention strategies and for monitoring the population impact of the HIV response, gifts should be considered as a supportive intervention for HIV-testing initiatives where consent rates have been low.

Using interviewer random effects to remove selection bias from HIV prevalence estimates.

BACKGROUND: Selection bias in HIV prevalence estimates occurs if non-participation in testing is correlated with HIV status. Longitudinal data suggests that individuals who know or suspect they are HIV positive are less likely to participate in testing in HIV surveys, in which case methods to correct for missing data which are based on imputation and observed characteristics will produce biased results. METHODS: The identity of the HIV survey interviewer is typically associated with HIV testing participation, but is unlikely to be correlated with HIV status. Interviewer identity can thus be used as a selection variable allowing estimation of Heckman-type selection models. These models produce asymptotically unbiased HIV prevalence estimates, even when non-participation is correlated with unobserved characteristics, such as knowledge of HIV status. We introduce a new random effects method to these selection models which overcomes non-convergence caused by collinearity, small sample bias, and incorrect inference in existing approaches. Our method is easy to implement in standard statistical software, and allows the construction of bootstrapped standard errors which adjust for the fact that the relationship between testing and HIV status is uncertain and needs to be estimated. RESULTS: Using nationally representative data from the Demographic and Health Surveys, we illustrate our approach with new point estimates and confidence intervals (CI) for HIV prevalence among men in Ghana (2003) and Zambia (2007). In Ghana, we find little evidence of selection bias as our selection model gives an HIV prevalence estimate of 1.4% (95% CI 1.2% - 1.6%), compared to 1.6% among those with a valid HIV test. In Zambia, our selection model gives an HIV prevalence estimate of 16.3% (95% CI 11.0% - 18.4%), compared to 12.1% among those with a valid HIV test. Therefore, those who decline to test in Zambia are found to be more likely to be HIV positive. CONCLUSIONS: Our approach corrects for selection bias in HIV prevalence estimates, is possible to implement even when HIV prevalence or non-participation is very high or very low, and provides a practical solution to account for both sampling and parameter uncertainty in the estimation of confidence intervals. The wide confidence intervals estimated in an example with high HIV prevalence indicate that it is difficult to correct statistically for the bias that may occur when a large proportion of people refuse to test.

Results of a 5-week schedule of modern total skin electron beam radiation therapy.

PURPOSE: To report the outcomes of a 5-week schedule of total skin electron beam radiation therapy (TSEB) for mycosis fungoides (MF). METHODS: Over 5 years, 41 patients with confirmed MF were treated with a modern TSEB technique delivering 30 Gy in 20 fractions over 5 weeks to the whole skin surface. Data were collected prospectively and entered into the skin tumor unit research database. Skin modified skin weighted assessment tool score data were collected to determine response, duration of response, survival, and toxicity. The outcomes were analyzed according to the patient's stage before TSEB, prognostic factors, and adjuvant treatments. RESULTS: Seventeen patients were stage 1B, 19 were stage IIB, 3 were stage III, and 2 were stage IV. The overall response rate was 95%, with a complete response rate of 51%. Seventy-six percent of patients had relapsed at median follow-up of 18 months. The median time to relapse was 12 months, to systemic therapy was 15 months, and to modified skin weighted assessment tool progression above baseline was 44 months. The complete response rate was 59% in stage IB and 47% in stage IIB patients. The median time to skin relapse was longer in stage IB compared with stage IIB, 18 months versus 9 months. The median time to systemic therapy was longer in stage IB compared with stage IIB, >56 months versus 8 months. The median overall survival was 35 months: >56 months for stage IB, 25 months for stage IIB, 46 months for stage III, and 23.5 months for stage IV. Fifteen patients received adjuvant psoralen + ultraviolet A treatment with no difference seen in the time to relapse. CONCLUSIONS: This 5-week schedule of TSEB for MF has a high response rate with comparable duration of response to other regimens. Future studies are needed to find adjuvant and combination treatments to improve the duration of response.