People who use drugs engagement in substance use disorder services and harm reduction: evaluation, challenges and future direction of a community-based intervention.

BACKGROUND: Since 1996, an urban community-based organization whose primary mission is to serve diverse94 and emerging community health needs has provided screening, testing, overdose prevention and training, referrals, and access to treatment for substance use disorders (SUD) and communicable diseases such as HIV through its Life Points harm reduction program. METHODS: As a partner in a State survey in 2021, the community organization recruited a convenience sample of people who use drugs to participate in a survey focused on their substance use, healthcare, and barriers to SUD services. Community health workers conducted outreach and used an encrypted identifier to collect data from a convenience sample of harm reduction participants regarding demographics, legal justice, engagement in harm reduction and access to healthcare. Evaluators entered paper surveys into Qualtrics for reporting and summative analysis. RESULTS: A convenience sample of fifty-five people who use drugs were recruited and surveyed. The majority (86%, n = 47) were active participants in the agency Life Points (LP) harm reduction service. Participants' average age was 42.9 years (SD = 11.5). About half (51%, n = 28) were male, 48% (n = 26) were female, and 2% (n = 1) was transgender. About two-thirds (67%, n = 37) of participants were White/Caucasian, 13% (n = 7) were Black/African-American, 11% (n = 6) were Hispanic and 7% (n = 4) were Multi-Racial. Regarding current substance use, 98% (n = 54) reported use of heroin, 51% (n = 28) reported crack, 47% (n = 26) cocaine, 25% (n = 14) alcohol, 24% (n = 13) opioids, and 15% (n = 8) marijuana. The majority, 87% (n = 48) said they had health care insurance and over two-thirds (69%, n = 37) said they had been arrested for a felony. Almost three quarters (71%, n = 39) reported receiving services from the Department of Health & Human Services. A higher percentage of females compared to males (65% and 29% respectively) reported engagement in community mental health services and 69% of females (n = 18) compared to 15% (n = 4) of males reported needing to participate in sex to meet basic social needs. Participants described social determinants of health as barriers to services, including access to food, legal justice and transportation. About 44% (n = 24) said they would consider enrolling in a drug treatment program in the next 30 days. CONCLUSION: This sample was reflective of increased participation by White participants that began to appear about a decade ago. The majority of participants reported having healthcare insurance, which may be reflective of engagement with community health workers to access appropriate services. Community organizations and healthcare professionals should continue to explore social determinants of health that can impact the health of people who use drugs, including overcoming barriers to health care access such as investing in mobile unit outreach.

Using the cardiovascular risk profile in a community heart health outreach intervention: Implications for primary care.

Context: "HeartB," a community heart health intervention and academic partnership, focused on urban African African urban at high risk for heart disease, was implemented by community health workers (CHW) and a community nurse. Objective: The primary objective was to reduce heart disease risk in Detroit by increasing participants' knowledge of heart disease, with a secondary objective of facilitating prevention of developing heart disease by increasing understanding of how to lower risks for heart disease. Study Design and Analysis: Quasi-experimental (pre-post) design and six-month follow-up. Setting: Population health. Population: Adult (18 years or older) residing in an African-American majority city catchement. Intervention: A community nurse and CHW were cross-trained and used the The National Heart, Lung and Blood Institute (NHLBI) evidence-based family-focused "With Every HeartBeat Is Life: A Community Health Workers Manual for African Americans" with the Framingham Heart Study "General Cardiovascular Risk Profile for Use in Primary Care." Outcome: The community nurse and CHW successfully recruited adults at high risk for cardiovascular disease from 27 zipcodes throughout the city, primarily from community organizations and churches. Six-month follow-up was completed with 96% of participants. Results: The 100 participants were 55% Female, 39% Male and 6% Transgender, with a mean age of 44.57 years (s.d.=15.9) and 97% were African-American. 92% reported having a primary care physician, with about half (52%) on Medicare/Medicaid. Following collection of family history information, participants met with the project nurse and CHW for clinical assessments, (weight, BP and medical history) and to discuss their cardiovascular risk factors. Based on the clinical assessment and medical history, the Framingham Heart Study Risk Assessment non-lab tool (D'Agostino, 2007) was used to provide the participants with their heart age and CVD risk for developing heart disease in the next ten years. 54% had <10% probability of a CVD event in the next 10 years, 26% had between a 10-19% probability, and 20% had a 20%/greater probability. Conclusions: Primary care physicians should be encouraged to work with CHW in African American communities to conduct long-term interventions to determine effective strategies for cardiovascular risk reduction.

Willingness to pay and willingness to accept in a patient-centered blood pressure control study.

BACKGROUND: Elevated blood pressure is a major risk factor for cardiovascular disease and stroke but patients often discount recommended behavioral changes and prescribed medications. While effective interventions to promote adherence have been developed, cost-effectiveness from the patient's perspective, has not been well studied. The valuation of patient time and out of pocket expenses should be included while performing cost effectiveness evaluation. The Achieve BP study uses the contingent valuation method to assess willingness to accept (WTA) and willingness to pay (WTP) among patients with a history of uncontrolled blood pressure discharged from an urban emergency department and enrolled in a larger randomized controlled trial. METHODS: WTA and WTP were assessed by asking patients a series of questions about time and travel costs and time value related to their study participation. A survey was conducted during the final study visit with patients to investigate the effectiveness of a kiosk-based educational intervention on blood pressure control. All study patients, regardless of study arm, received the same clinical protocol of commonly prescribed antihypertensive medication and met with research clinicians four times as part of the study procedures. RESULTS: Thirty-eight patients were offered the opportunity to participate in the cost-effectiveness study and all completed the survey. Statistical comparisons revealed these 38 patients were similar in representation to the entire RCT study population. All 38 (100.0%) were African-American, with an average age of 49.1 years; 55.3% were male, 21.1% were married, 78.9% had a high school or higher education, and 44.7% were working. 55.9% did not have a primary care provider and 50.0% did not have health insurance. Time price linear regression analysis was performed to estimate predictors of WTA and WTP. CONCLUSIONS: WTP and WTA may generate different results, and the elasticities were proportional to the estimated coefficients, with WTP about twice as responsive as WTA. An additional feature for health services research was successful piloting in a clinical setting of a brief patient-centered cost effectiveness survey. TRIAL REGISTRATION: https://clinicaltrials.gov . Registration Number NCT02069015 . Registered February 19, 2014 (Retrospectively registered).

The relationship between combination inhaled corticosteroid and long-acting ß-agonist use and severe asthma exacerbations in a diverse population.

BACKGROUND: Safety concerns surround the use of long-acting ß-agonists (LABAs) for the treatment of asthma, even in combination with inhaled corticosteroids (ICSs) and particularly in high-risk subgroups. OBJECTIVE: To estimate the effect of ICS therapy and fixed-dose ICS/LABA combination therapy on severe asthma exacerbations in a racially diverse population. METHODS: ICS and ICS/LABA exposure was estimated from pharmacy data for patients with asthma aged 12 to 56 years who were members of a large health maintenance organization. ICS and ICS/LABA use was estimated for each day of follow-up to create a moving window of exposure. Proportional hazard models were used to assess the relationship between ICS and ICS/LABA combination therapy and severe asthma exacerbations (ie, use of oral corticosteroids, asthma-related emergency department visit, or asthma-related hospitalization). RESULTS: Among the 1828 patients who met the inclusion criteria, 37% were African American, 46% were treated with ICS therapy alone, and 54% were treated with an ICS/LABA combination. Models assessing the risk of severe asthma exacerbations among individuals using ICS treatment alone and ICS/LABA combination therapy suggested that the overall protective effect was as good or better for ICS/LABA combination therapy when compared with ICS treatment alone (hazard ratio, 0.65 vs 0.72, respectively). Analyses in several subgroups, including African American patients, showed a similar statistically significant protective association for combination therapy. CONCLUSION: Treatment with ICS/LABA fixed-dose combination therapy appeared to perform as well as or better than ICS treatment alone in reducing severe asthma exacerbations; this included multiple high-risk subgroups.