A Brief Tool to Screen Patients for Precarious Employment: A Validation Study.

PURPOSE: Precarious employment, defined by temporary contracts, unstable employment, or job insecurity, is increasingly common and is associated with inconsistent access to benefits, lower income, and greater exposure to physical and psycholosocial hazards. Clinicians can benefit from a simple approach to screen for precarious employment to improve their understanding of a patient's social context, help with diagnoses, and inform treatment plans and intersectional interventions. Our objective was to validate a screening tool for precarious employment. METHODS: We used a 3-item screening tool that covered key aspects of precarious employment: non-standard employment, variable income, and violations of occupational health and safety rights and protections. Answers were compared with classification using the Poverty and Employment Precarity in Southern Ontario Employment Index. Participants were aged 18 years and older, fluent in English, and employed. They were recruited in 7 primary care clinic waiting rooms in Toronto, Canada over 12 months. RESULTS: A total of 204 people aged 18-72 years (mean 38 [SD 11.3]) participated, of which 93 (45.6%) identified as men and 119 (58.3%) self-reported as White. Participants who reported 2 or more of the 3 items as positive were almost 4 times more likely to be precariously employed (positive likelihood ratio = 3.84 [95% CI, 2.15-6.80]). CONCLUSIONS: A 3-item screening tool can help identify precarious employment. Our tool is useful for starting a conversation about employment precarity and work conditions in clinical settings. Implementation of this screening tool in health settings could enable better targeting of resources for managing care and connecting patients to legal and employment support services.

"When I think about my future, I just see darkness": How youth exiting homelessness navigate the hazy, liminal space between socioeconomic exclusion and inclusion.

OBJECTIVES: The overarching objective of this mixed methods longitudinal study was to understand whether and how rent subsidies and mentorship influenced socioeconomic inclusion outcomes for youth exiting homelessness. The focus of this paper is on the qualitative objectives, which evolved from a primary focus on exploring how study mentorship was working as a facilitator of socioeconomic inclusion to focusing on how participants navigated the hazy, liminal space between socioeconomic exclusion and inclusion. METHODS: This was a convergent mixed methods study scaffolded by community-based participatory action axiology. The quantitative component is reported elsewhere and involved a 2-year pilot randomized controlled trial where 24 participants received rent subsidies and 13 were randomly assigned a study mentor; proxy indicators of socioeconomic inclusion were measured every 6 months for 2.5 years. Qualitative objectives were explored using a qualitative descriptive design and theoretically framed using critical social theory. The lead author interviewed 12 participants every 6 months for 2.5 years. Qualitative interviews were analyzed using reflexive thematic analysis with an emphasis on critical interpretation. RESULTS: Navigating the liminal space between socioeconomic exclusion and inclusion was complex and non-linear, and the way youth navigated that journey was more strongly associated with factors like informal mentorship (naturally occurring "coach-like" mentorship) and identity capital (sense of purpose, control, self-efficacy, and self-esteem), rather than whether or not they were assigned a formal study mentor. CONCLUSION: A holistic approach integrating coaching and attention to identity capital alongside economic supports may be key to helping youth exiting homelessness achieve socioeconomic inclusion.

RéSUMé: OBJECTIFS: L'objectif primordial de cette étude longitudinale à méthodes mixtes était de comprendre si et comment les suppléments au loyer et le mentorat influencent les résultats sur le plan de l'inclusion socioéconomique pour les jeunes qui sortent du sans-abrisme. Notre article porte sur des objectifs qualitatifs; à l'origine, il visait principalement à explorer l'efficacité du mentorat des études comme moyen de faciliter l'inclusion socioéconomique, puis il a évolué en s'attachant à la manière dont les participantes et les participants trouvaient leurs repères dans l'espace liminaire flou entre l'exclusion et l'inclusion socioéconomique. MéTHODE: Cette étude à méthodes mixtes convergentes est échafaudée sur l'axiologie de l'action participative communautaire. L'élément quantitatif, qui fait l'objet d'un autre article, a impliqué un essai pilote comparatif randomisé de deux ans où 24 participantes et participants ont reçu des suppléments au loyer, et 13 ont été jumelés de façon aléatoire à un tuteur ou une tutrice scolaire; des indicateurs approximatifs de l'inclusion socioéconomique ont été mesurés tous les six mois pendant deux ans et demi. Les objectifs qualitatifs ont été explorés à l'aide d'un protocole descriptif qualitatif et encadrés théoriquement par la théorie sociale critique. L'autrice principale a interviewé 12 participantes et participants tous les six mois pendant deux ans et demi. Les entretiens qualitatifs ont été analysés en employant l'analyse thématique réflexive et en mettant l'accent sur l'interprétation critique. RéSULTATS: L'exploration de l'espace liminaire entre l'exclusion et l'inclusion socioéconomique était complexe et non linéaire, et le parcours des jeunes était davantage associé à des facteurs comme le mentorat informel (le mentorat naturel semblable à celui d'un entraîneur ou d'une entraîneuse) et le capital identitaire (le sentiment d'avoir un but, le contrôle, l'auto-efficacité et l'estime de soi) qu'au fait d'avoir ou non été jumelés à un tuteur ou une tutrice dans leurs études. CONCLUSION: Une démarche holistique intégrant l'encadrement et l'attention au capital identitaire, en plus des mesures de soutien économique, pourrait être essentielle pour aider les jeunes qui sortent du sans-abrisme à s'intégrer sur le plan socioéconomique.

Formation and Assessment of a Laryngology Pathology Video Atlas for Resident Education.

OBJECTIVE: Conventional reference images of laryngeal pathologies may provide educational value for Otolaryngology-Head & Neck Surgery (OHNS) residents, but observing dynamic vocal fold function is critical for diagnosis. Our aim was to develop and validate a video atlas of laryngeal pathologies for resident education in OHNS. DESIGN: A multi-institution, prospective case-control study. SETTING/PARTICIPANTS: Ten videos showing 10 representative laryngeal pathologies were verified by two laryngologists. Six videos per category with kappa>0.8 were included in the video database. A collection of the videos was shown to a group of OHNS residents in a quiz fashion to determine if senior trainees would score higher than junior trainees. Another group of residents in OHNS was recruited and randomized to control or intervention. The control group was shown a quiz of 10 laryngeal videos at baseline and 24 weeks later. The intervention group was shown quizzes at baseline and every 6 weeks, ending at 24 weeks. Free-text diagnoses were scored for accuracy. Descriptive statistics, two-tailed tests, and analysis of covariance were performed. RESULTS: Twenty-nine residents participated, with 14 (48.3%) randomized to control, and 15 (51.7%) to the intervention. The postgraduate year (PGY) level had a significant impact on diagnostic performance. PGY1 and 2 had a significantly lower score than PGY5 (P = 0.017 and P = 0.035, respectively). PGY3 and PGY4 scores were not statistically different from PGY5 scores. The mean score difference between groups decreases as the PGY level increases (mean difference between groups = 0.87, P = 0.153), but this was not significant. CONCLUSIONS: The current study has created a validated collection of videos that are representative of common laryngeal pathologies and can be easily incorporated into resident video-based learning. Future directions include larger multi-site studies to further elucidate whether repeated viewing of this video atlas can improve OHNS resident laryngology knowledge.

A Pragmatic Randomized Controlled Trial of Financial Incentives in Case Management for Homeless Adults With Mental Illness.

OBJECTIVE: Financial incentives can facilitate behavior change and service engagement in health care settings, but research on their use with adults experiencing homelessness is limited. This study examined the effectiveness of financial incentives in improving service engagement and health outcomes among homeless adults with mental illness in Toronto. METHODS: The authors of this randomized controlled trial recruited 176 participants receiving brief multidisciplinary case management services for homeless adults with mental illness after hospital discharge. In a 1:1 randomization design, 87 participants received a financial incentive of CAN$20 for every week they remained engaged with the service for up to 6 months. The remaining 89 participants received treatment as usual. The primary outcome was service contact rates for up to 6 months of follow-up. Secondary outcomes included self-reported health status, mental health symptoms, substance use, quality of life, housing stability, acute health service use, and working alliance. Negative binomial regression models, analyses of covariance, generalized estimating equations models, and Wilcoxon rank sum tests were used to examine differences between the financial incentive and treatment-as-usual groups across outcomes of interest. RESULTS: No significant differences were found between the financial incentive and treatment-as-usual groups in service contact rates or any of the secondary outcomes examined over the 6-month period. CONCLUSIONS: In low-barrier, brief case management programs tailored to the needs of adults experiencing homelessness, financial incentives may not affect service engagement or health outcomes. Further research is needed to identify the effect of financial incentives on engagement in other services, including housing-based interventions.

Evaluating the Impact of a Critical Time Intervention Adaptation on Health Care Utilization among Homeless Adults with Mental Health Needs in a Large Urban Center.

OBJECTIVE: This study evaluated the impact of a critical time intervention (CTI) adaptation on health care utilization outcomes among adults experiencing homelessness and mental health needs in a large urban center. METHODS: Provincial population-based administrative data from Ontario, Canada, were used in a pre-post design for a cohort of 197 individuals who received the intervention between January 2013 and May 2014 and were matched to a cohort of adults experiencing homelessness who did not receive the intervention over the same time period. Changes in health care utilization outcomes in the year pre- and postintervention were evaluated using generalized estimating equations, and post hoc analyses evaluated differences between groups. RESULTS: Pre-post analyses revealed statistically significant changes in health care utilization patterns among intervention recipients, including reduced inpatient service use and increased outpatient service use in the year following the intervention compared to the year prior. However, the matched cohort analysis found nonsignificant differences in health service use changes between a subgroup of intervention recipients and their matched counterparts. CONCLUSIONS: An adapted CTI model was associated with changes in health care utilization among people experiencing homelessness and mental health needs. However, changes were not different from those observed in a matched cohort. Rigorous study designs with adequate samples are needed to examine the effectiveness of CTI and local adaptations in diverse health care contexts.

Routinely asking patients about income in primary care: a mixed-methods study.

BACKGROUND: Income is a key social determinant of health, yet it is rare for data on income to be routinely collected and integrated with electronic health records. AIM: To examine response bias and evaluate patient perspectives of being asked about income in primary care. DESIGN & SETTING: Mixed-methods study in a large, multi-site primary care organisation in Toronto, Canada, where patients are asked about income in a routinely administered sociodemographic survey. METHOD: Data were examined from the electronic health records of patients who answered at least one question on the survey between December 2013 and March 2016 (n = 14 247). The study compared those who responded to the income question with non-responders. Structured interviews with 27 patients were also conducted. RESULTS: A total of 10 441 (73%) patients responded to both parts of the income question: 'What was your total family income before taxes last year?' and 'How many people does your income support?'. Female patients, ethnic minorities, caregivers of young children, and older people were less likely to respond. From interviews, many patients were comfortable answering the income question, particularly if they understood the connection between income and health, and believed the data would be used to improve care. Several patients found it difficult to estimate their income or felt the options did not reflect fluctuating financial circumstances. CONCLUSION: Many patients will provide data on income in the context of a survey in primary care, but accurately estimating income can be challenging. Future research should compare self-reported income to perceived financial strain. Data on income linked to health records can help identify health inequities and help target anti-poverty interventions.

Four-Year Trajectories of Health-Related Quality of Life in People Living with HIV: Impact of Unmet Basic Needs across Age Groups in Positive Spaces, Healthy Places.

Despite significant advances in antiretroviral therapy, unmet basic needs can negatively impact health-related quality of life (HRQoL) in people living with HIV, especially as they age. We aimed to examine the effect of unmet basic needs across age groups on changes in HRQoL over a 4-year period in persons with HIV. Physical and mental HRQoL scores from the Positive Spaces, Healthy Spaces cohort interviewed in 2006 (n = 538), 2007 (n = 506), and 2009 (n = 406) were examined across three age groups according to their unmet needs for food, clothing, and housing. Individual growth curve model analyses were used to investigate changes over time, adjusting for demographics, employment, living conditions, social supports, HIV status, and health behavior risks. Low scores on physical and mental HRQoL were positively associated with higher number of unmet basic needs (ß = -6.40, standard error (SE) = 0.87, p < 0.001 and ß = -7.39, SE = 1.00, p < 0.001, respectively). There was a slight improvement in physical and mental HRQoL over 4 years in this HIV cohort, but the burden of unmet basic needs took its toll on those over 50 years of age. Regularly assessing unmet basic needs is recommended given the impact these can have on HRQOL for people living with HIV. Recognition of unmet needs is vital, as is the development of timely interventions.

The Impact of Financial Incentives on Service Engagement Among Adults Experiencing Homelessness and Mental Illness: A Pragmatic Trial Protocol.

Background: People experiencing homelessness and mental illness have poorer service engagement and health-related outcomes compared to the general population. Financial incentives have been associated with increased service engagement, but evidence of effectiveness is limited. This protocol evaluates the acceptability and impact of financial incentives on service engagement among adults experiencing homelessness and mental illness in Toronto, Canada. Methods: This study protocol uses a pragmatic field trial design and mixed methods (ClinicalTrials.gov Identifier: NCT03770221). Study participants were recruited from a brief multidisciplinary case management program for adults experiencing homelessness and mental illness following hospital discharge, and were randomly assigned to usual care or a financial incentives arm offering $20 for each week they attended meetings with a program provider. The primary outcome of effectiveness is service engagement, measured by the count of participant-provider health-care contacts over the 6-month period post-randomization. Secondary health, health service use, quality of life, and housing outcomes were measured at baseline and at 6-month follow-up. Quantitative data will be analyzed using descriptive statistics and inferential modeling including Poisson regression and generalized estimating equations. A subset of study participants and other key informants participated in interviews, and program staff in focus groups, to explore experiences with and perspectives regarding financial incentives. Qualitative data will be rigorously coded and thematically analyzed. Conclusions: Findings from this study will contribute high quality evidence to an underdeveloped literature base on the effectiveness and acceptability of financial incentives to improve service engagement and health-related outcomes among adults experiencing homelessness and mental illness.

Suboptimal iron deficiency screening in pregnancy and the impact of socioeconomic status in a high-resource setting.

Iron deficiency (ID) anemia in pregnancy is associated with poor maternal and childhood outcomes, yet ferritin testing, the standard test for ID, is not considered part of routine prenatal bloodwork in Canada. We conducted a retrospective cohort study of 44 552 pregnant patients with prenatal testing at community laboratories in Ontario, Canada, to determine the prevalence of ferritin testing over 5 years. Secondary objectives were to determine the prevalence and severity of ID and to identify clinical and demographic variables that influence the likelihood of ID screening. A total of 59.4% of patients had a ferritin checked during pregnancy; 71.4% were ordered in the first trimester, when the risk of ID is lowest. Excluding patients with abnormally elevated ferritins, 25.2% were iron insufficient (30-44 µg/L) and 52.8% were iron deficient (≤29 µg/L) at least once in pregnancy. A total of 8.3% were anemic (hemoglobin <105 g/L). The proportion of anemic patients with a subsequent ferritin test in pregnancy ranged from 22% to 67% in the lowest and highest anemia severity categories, respectively. Lower annual household income was negatively associated with the odds of a ferritin test; compared with those in the fifth (ie, highest) income quintile, the odds of ferritin testing for patients in the first, second, and fourth quintiles were 0.83 (95% confidence interval [CI], 0.74-0.91), 0.82 (95% CI, 0.74-0.91), and 0.86 (95% CI, 0.77-0.97), respectively. These data highlight gaps in prenatal care and issues of health equity that warrant harmonization of obstetrical guidelines to recommend routine ferritin testing in pregnancy.

Does Housing Improve Health Care Utilization and Costs? A Longitudinal Analysis of Health Administrative Data Linked to a Cohort of Individuals With a History of Homelessness.

BACKGROUND: Individuals who are homeless have complex health care needs, which contribute to the frequent use of health services. In this study, we investigated the relationship between housing and health care utilization among adults with a history of homelessness in Ontario. METHODS: Survey data from a 4-year prospective cohort study were linked with administrative health records in Ontario. Annual rates of health encounters and mean costs were compared across housing categories (homeless, inconsistently housed, housed), which were based on the percentage of time an individual was housed. Generalized estimating equations were applied to estimate the average annual effect of housing status on health care utilization and costs. RESULTS: Over the study period, the proportion of individuals who were housed increased from 37% to 69%. The unadjusted rates of ambulatory care visits, prescription medications, and laboratory tests were highest during person-years spent housed or inconsistently housed and the rate of emergency department visits was lowest during person-years spent housed. Following adjustment, the rate of prescription claims remained higher during person-years spent housed or inconsistently housed compared with the homeless. Rate ratios for other health care encounters were not significant (P>0.05). An interaction between time and housing status was observed for total health care costs; as the percentage of days housed increased, the average costs increased in year 1 and decreased in years 2-4. CONCLUSIONS: These findings highlight the effects of housing on health care encounters and costs over a 4-year study period. The rate of prescription medications was higher during person-years spent housed or inconsistently housed compared with the homeless. The cost analysis suggests that housing may reduce health care costs over time; however, future work is needed to confirm the reason for the reduction in total costs observed in later years.

Routine identification of patients with disabilities in primary care: A mixed-methods study.

BACKGROUND: People with disabilities experience barriers to receiving healthcare and often have worse health outcomes, but data on disability is rarely routinely collected in a standardized way. OBJECTIVE: This study examined how patients responded to being asked about disabilities as part of a routine, self-administered sociodemographic survey. METHODS: We conducted a mixed-methods study in a multi-site primary care organization. We compared the characteristics of people who responded to a question about disabilities to those who did not respond using logistic regression. We also compared survey responses to data available in medical charts. In-depth interviews were conducted with a sample of patients following survey completion. RESULTS: Over 28 months, 15,221 patients were offered the survey and 14,247 (93.6%) responded to at least one question. Of these, 11,275 (79.1%) patients answered the question about disabilities. Older patients, patients who rented their home, and non-White patients were less likely to respond to the question. When comparing survey responses to data from medical charts we identified discrepancies. Patients interviewed reported they had difficulty judging what constituted a disability. Stigma related to mental illness and substance use led them to avoid disclosing those conditions. CONCLUSIONS: Directly asking patients whether they have a disability may be challenging given confusion about what constitutes a disability and stigma associated with certain disabilities. Future research should examine whether asking about barriers faced in accessing health services could adequately identify patients with disabilities and also be used to identify tangible actions an organization could take to lower barriers to care.

Development of the Functional Assessment of Cancer Therapy-Immune Checkpoint Modulator (FACT-ICM): A toxicity subscale to measure quality of life in patients with cancer who are treated with ICMs.

BACKGROUND: Patients with cancer who are treated with immune checkpoint modulators (ICMs) have their health-related quality of life (HRQOL) measured using general patient-reported outcome (PRO) tools. To the authors' knowledge, no instrument has been developed to date specifically for patients treated with ICMs. The objective of the current study was to develop a toxicity subscale PRO instrument for patients treated with ICMs to assess HRQOL. METHODS: Input was collected from a systematic review as well as patients and physicians experienced with ICM treatment. Descriptive thematic analysis was used to evaluate the qualitative data obtained from patient focus groups and interviews, which informed an initial list of items that described ICM side effects and their impact on HRQOL. These inputs informed item generation and/or reduction to develop a toxicity subscale. RESULTS: Focus groups and individual interviews with 37 ICM-treated patients generated an initial list of 176 items. After a first round of item reduction that produced a shortened list of 76 items, 16 physicians who care for patients who are treated with ICMs were surveyed with a list of 49 patient-reported side effects and 11 physicians participated in follow-up interviews. A second round of item reduction was informed by the physician responses to produce a list of 25 items. CONCLUSIONS: To the authors' knowledge, this 25-item list is the first HRQOL-focused toxicity subscale for patients treated with ICMs and was developed in accordance with US Food and Drug Administration guidelines, which prioritize patient input in developing PRO tools. The subscale will be combined with the Functional Assessment of Cancer Therapy-General (FACT-G) to form the FACT-ICM. Prior to recommending the formal use of this PRO instrument, the authors will evaluate its validity and reliability in longitudinal studies involving substantially more patients.

Unmet health needs and discrimination by healthcare providers among an Indigenous population in Toronto, Canada.

OBJECTIVES: Inequalities between Indigenous and non-Indigenous peoples in Canada persist. Despite the growth of Indigenous populations in urban settings, information on their health is scarce. The objective of this study is to assess the association between experience of discrimination by healthcare providers and having unmet health needs within the Indigenous population of Toronto. METHODS: The Our Health Counts Toronto (OHCT) database was generated using respondent-driven sampling (RDS) to recruit 917 self-identified Indigenous adults within Toronto for a comprehensive health assessment survey. This cross-sectional study draws on information from 836 OHCT participants with responses to all study variables. Odds ratios and 95% confidence intervals were estimated to examine the relationship between lifetime experience of discrimination by a healthcare provider and having an unmet health need in the 12 months prior to the study. Stratified analysis was conducted to understand how information on access to primary care and socio-demographic factors influenced this relationship. RESULTS: The RDS-adjusted prevalence of discrimination by a healthcare provider was 28.5% (95% CI 20.4-36.5) and of unmet health needs was 27.3% (95% CI 19.1-35.5). Discrimination by a healthcare provider was positively associated with unmet health needs (OR 3.1, 95% CI 1.3-7.3). CONCLUSION: This analysis provides new evidence linking discrimination in healthcare settings to disparities in healthcare access among urban Indigenous people, reinforcing existing recommendations regarding Indigenous cultural safety training for healthcare providers. Our study further demonstrates Our Health Counts methodologies, which employ robust community partnerships and RDS to address gaps in health information for urban Indigenous populations.

Validation study of health administrative data algorithms to identify individuals experiencing homelessness and estimate population prevalence of homelessness in Ontario, Canada.

OBJECTIVES: To validate case ascertainment algorithms for identifying individuals experiencing homelessness in health administrative databases between 2007 and 2014; and to estimate homelessness prevalence trends in Ontario, Canada, between 2007 and 2016. DESIGN: A population-based retrospective validation study. SETTING: Ontario, Canada, from 2007 to 2014 (validation) and 2007 to 2016 (estimation). PARTICIPANTS: Our reference standard was the known housing status of a longitudinal cohort of housed (n=137 200) and homeless or vulnerably housed (n=686) individuals. Two reference standard definitions of homelessness were adopted: the housing episode and the annual housing experience (any homelessness within a calendar year). MAIN OUTCOME MEASURES: Sensitivity, specificity, positive and negative predictive values and positive likelihood ratios of 30 case ascertainment algorithms for detecting homelessness using up to eight health service databases. RESULTS: Sensitivity estimates ranged from 10.8% to 28.9% (housing episode definition) and 18.5% to 35.6% (annual housing experience definition). Specificities exceeded 99% and positive likelihood ratios were high using both definitions. The most optimal algorithm estimates that 59 974 (95% CI 55 231 to 65 208) Ontarians (0.53% of the adult population) experienced homelessness in 2016, a 67.3% increase from 2007. CONCLUSIONS: In Ontario, case ascertainment algorithms for identifying homelessness had low sensitivity but very high specificity and positive likelihood ratio. The use of health administrative databases may offer opportunities to track individuals experiencing homelessness over time and inform efforts to improve housing and health status in this vulnerable population.

Assessment of left ventricular function by CMR versus MUGA scans in breast cancer patients receiving trastuzumab: a prospective observational study.

Little is known about the comparison of multiple-gated acquisition (MUGA) scanning with cardiovascular magnetic resonance (CMR) for serial monitoring of HER2+ breast cancer patients receiving trastuzumab. The association of cardiac biomarkers with CMR left ventricular (LV) function and volume is also not well studied. Our objectives were to compare CMR and MUGA for left ventricular ejection fraction (LVEF) assessment, and to examine the association between changes in brain natriuretic peptide (NT-BNP) and troponin-I and changes in CMR LV function and volume. This prospective longitudinal two-centre cohort study recruited HER2+ breast cancer patients between January 2010 and December 2013. MUGA, CMR, NT-BNP and troponin-I were performed at baseline, 6, 12, and 18 months after trastuzumab initiation. In total, 41 patients (age 51.7 ± 10.8 years) were enrolled. LVEF comparison between MUGA and CMR demonstrated weak agreement (Lin's correlation coefficient r = 0.46, baseline; r = 0.29, 6 months; r = 0.42, 12 months; r = 0.39, 18 months; all p < 0.05). Bland-Altman plots demonstrated wide LVEF agreement limits (pooled agreement limits 3.0 ± 6.2). Both modalities demonstrated significant LVEF decline at 6 and 12 months from baseline, concomitant with increased LV volumes on CMR. Changes in NT-BNP correlated with changes in LV diastolic volume at 12 and 18 months (p < 0.05), and LV systolic volume at 18 months (p < 0.05). Changes in troponin-I did not correlate with changes in LV function or volume at any timepoint. In conclusion, CMR and MUGA LVEF are not interchangeable, warranting selection and utility of one modality for serial monitoring. CMR is useful due to less radiation exposure and accuracy of LV volume measurements. Changes in NT-BNP correlated with changes in LV volumes.

Routine collection of sexual orientation and gender identity data: a mixed-methods study.

BACKGROUND: Sexual orientation and gender identity are key social determinants of health, but data on these characteristics are rarely routinely collected. We examined patients' reactions to being asked routinely about their sexual orientation and gender identity, and compared answers to the gender identity question against other data in the medical chart on gender identity. METHODS: We analyzed data on any patient who answered at least 1 question on a routinely administered sociodemographic survey between Dec. 1, 2013, and Mar. 31, 2016. We also conducted semistructured interviews with 27 patients after survey completion. RESULTS: The survey was offered to 15 221 patients and 14 247 (93.6%) responded to at least 1 of the sociodemographic survey questions. Most respondents answered the sexual orientation (90.6%) and gender identity (96.1%) questions. Many patients who had been classified as transgender or gender diverse in their medical chart did not self-identify as transgender, but rather selected female (22.9%) or male (15.4%). In the semistructured interviews, many patients expressed appreciation at the variety of options available, although some did not see their identities reflected in the options and some felt uncomfortable answering the questions. INTERPRETATION: We found a high response rate to questions about sexual orientation and gender identity. Fitting with other research, we suggest using a 2-part question to explore gender identity. Future research should evaluate the acceptability and feasibility of administering these questions in a variety of care settings. These data can help organizations identify health inequities related to sexual orientation and gender identity.

Bridging Hospital and Community Care for Homeless Adults with Mental Health Needs: Outcomes of a Brief Interdisciplinary Intervention.

OBJECTIVE: This study examines health and service use outcomes and associated factors among homeless adults participating in a brief interdisciplinary intervention following discharge from hospital. METHOD: Using a pre-post cohort design, 223 homeless adults with mental health needs were enrolled in the Coordinated Access to Care for the Homeless (CATCH) program, a 4- to 6-month interdisciplinary intervention offering case management, peer support, access to primary psychiatric care, and supplementary community services. Study participants were interviewed at program entry and at 3- and 6-month follow-up visits and assessed for health status, acute care service use, housing outcomes, mental health, substance use, quality of life, and their working alliance with service providers. Linear mixed models and generalized estimating equations were performed to examine outcomes longitudinally. Additional post hoc analyses evaluated differences between CATCH participants and a comparison group of homeless adults experiencing mental illness who received usual services over the same period. RESULTS: In the pre-post analyses, CATCH participants had statistically significant improvements in mental and physical health status and reductions in mental health symptoms, substance misuse, and the number of hospital admissions. The strength of the working alliance between participants and their case manager was associated with reduced health care use and mental health symptoms. Post hoc analyses suggest that CATCH may be associated with statistically significant improvements in mental health symptoms in the study population. CONCLUSIONS: A brief interdisciplinary intervention may be a promising approach to improving health outcomes among homeless adults with unmet health needs. Further rigorous research is needed into the effectiveness of brief interventions following discharge from hospital.

The effectiveness of an integrated collaborative care model vs. a shifted outpatient collaborative care model on community functioning, residential stability, and health service use among homeless adults with mental illness: a quasi-experimental study.

BACKGROUND: Although a growing number of collaborative mental health care models have been developed, targeting specific populations, few studies have utilized such interventions among homeless populations. This quasi-experimental study compared the outcomes of two shelter-based collaborative mental health care models for men experiencing homelessness and mental illness: (1) an integrated multidisciplinary collaborative care (IMCC) model and (2) a less resource intensive shifted outpatient collaborative care (SOCC) model. METHODS: In total 142 participants, 70 from IMCC and 72 from SOCC were enrolled and followed for 12 months. Outcome measures included community functioning, residential stability, and health service use. Multivariate regression models were used to compare study arms with respect to change in community functioning, residential stability, and health service use outcomes over time and to identify baseline demographic, clinical or homelessness variables associated with observed changes in these domains. RESULTS: We observed improvements in both programs over time on measures of community functioning, residential stability, hospitalizations, emergency department visits and community physician visits, with no significant differences between groups over time on these outcome measures. CONCLUSIONS: Our findings suggest that shelter-based collaborative mental health care models may be effective for individuals experiencing homelessness and mental illness. Future studies should seek to confirm these findings and examine the cost effectiveness of collaborative care models for this population.

Effect of scattered-site housing using rent supplements and intensive case management on housing stability among homeless adults with mental illness: a randomized trial.

IMPORTANCE: Scattered-site housing with Intensive Case Management (ICM) may be an appropriate and less-costly option for homeless adults with mental illness who do not require the treatment intensity of Assertive Community Treatment. OBJECTIVE: To examine the effect of scattered-site housing with ICM services on housing stability and generic quality of life among homeless adults with mental illness and moderate support needs for mental health services. DESIGN, SETTING, AND PARTICIPANTS: The At Home/Chez Soi project was an unblinded, randomized trial. From October 2009 to July 2011, participants (N = 1198) were recruited in 4 Canadian cities (Vancouver, Winnipeg, Toronto, and Montreal), randomized to the intervention group (n = 689) or usual care group (n = 509), and followed up for 24 months. INTERVENTIONS: The intervention consisted of scattered-site housing (using rent supplements) and off-site ICM services. The usual care group had access to existing housing and support services in their communities. MAIN OUTCOMES AND MEASURES: The primary outcome was the percentage of days stably housed during the 24-month period following randomization. The secondary outcome was generic quality of life, assessed by a EuroQoL 5 Dimensions (EQ-5D) health questionnaire. RESULTS: During the 24 months after randomization, the adjusted percentage of days stably housed was higher among the intervention group than the usual care group, although adjusted mean differences varied across sites. [table: see text] The mean change in EQ-5D score from baseline to 24 months among the intervention group was not statistically different from the usual care group (60.5 [95%CI, 58.6 to 62.5] at baseline and 67.2 [95%CI, 65.2 to 69.1] at 24 months for the intervention group vs 62.1 [95% CI, 59.9 to 64.4] at baseline and 68.6 [95%CI, 66.3 to 71.0] at 24 months for the usual care group, difference in mean changes, 0.10 [95%CI, −2.92 to 3.13], P=.95). CONCLUSIONS AND RELEVANCE: Among homeless adults with mental illness in 4 Canadian cities, scattered site housing with ICM services compared with usual access to existing housing and community services resulted in increased housing stability over 24 months, but did not improve generic quality of life. TRIAL REGISTRATION: isrctn.org Identifier: ISRCTN42520374.

The effect of an organizational network for patient safety on safety event reporting.

Health care organizations continue to implement organization-wide educational approaches to enhance patient safety with less attention on evaluating the impact of these approaches. In this context, a study was conducted to measure the impact of an organization-wide patient safety network approach on patient safety event reporting. A time-series analysis with reported rates of adverse events (major and moderate), near misses, sentinel events, and incidents from 2 years prior through 13 months following implementation was conducted. Study findings include a significant increase in reporting of patient safety events (an approximately 50% increase in overall reporting of safety events was observed; p < .001), especially near misses (an approximately 100% increase following implementation; p = .002). Study findings suggest that a multifaceted networked approach does contribute to improving patient safety event reporting.