Looking for the uninsured in Massachusetts? Check opioid dependent persons seeking detoxification.

BACKGROUND: We examined the rate of uninsurance among persons seeking detoxification at a large drug treatment program in Massachusetts in 2013, five years after insurance mandates. METHODS: We interviewed three hundred and forty opioid dependent persons admitted for inpatient detoxification in Fall River, Massachusetts. Potential predictors of self-reported insurance status included age, gender, ethnicity, employment, homelessness, years of education, current legal status, and self-perceived health status. RESULTS: Participants mean age was 32 years, 71% were male, and 87% were non-Hispanic Caucasian. Twenty-three percent were uninsured. In the multivariate model, the odds of being uninsured was positively associated with years of education (OR=1.22, 95% CI=1.03; 1.46, p<.05), higher among males than females (OR=2.63, 95% CI=1.33; 5.20, p<.01), and inversely associated with age (OR=0.94, 95% CI=0.90; 0.98, p<.01). CONCLUSION: Opioid dependent persons recruited from a detoxification program in Massachusetts are uninsured at rates far above the state average. With the arrival of the Affordable Care Act, drug treatment programs in Massachusetts and nationally will be important sites to target to expand health coverage.

Relationship quality among HIV patients and their caregivers.

Despite the increasing attention to caregivers of HIV patients, no previous study has systematically investigated the effects of the relationship quality between an HIV patient and their caregiver. The present study assessed 176 dyads consisting of an HIV-infected patient and their self-identified 'caregiver'. Relationship quality was measured by the Family Assessment Device (FAD). Dependent measures included the Beck Depression Inventory, SF-36 Physical Functioning Scale, Caregiver Strain Index and 4-day HIV treatment adherence. A substantial proportion of HIV patient-caregiver dyads reported difficulties in their relationships (17-66% depending upon FAD scale). The level of relationship difficulties was not strongly related to the type of patient-caregiver relationship. However, the quality of the HIV patient-caregiver relationship was significantly associated (p<0.05) with caregiver depression and burden as well as HIV patient depression, physical functioning and HIV medication adherence, even when the potential effects of length of HIV infection and social support were controlled. These results suggest that relationship quality is impaired in many patient-caregiver dyads and is uniquely associated with levels of depression, caregiver burden and treatment adherence.

The clinical relevance of microbiologic testing: a comparative analysis of microbiologic samples secured from the same sites and cultured in two independent laboratories.

A field study using five different private periodontal practices was conducted; it compared two microbiologic culture samples simultaneously secured from the same sites within 23 individual patients and submitted for bacterial identification and antibiotic sensitivity testing to two separate laboratories. The results from the two laboratories were often different. In no instance did both laboratories agree on the presence of identical bacterial species. When only bacteria above threshold levels were compared, agreement was found in only nine of 23 cases. When examining antibiotic sensitivity, using 100% kill of all tested pathogens as the ideal, agreement between the two laboratories was poor. The laboratories agreed on the use of amoxicillin 17% of the time, tetracycline 26% of the time, and metronidazole 48% of the time. The use of amoxicillin and metronidazole in combination yielded a 78% agreement when the results of both laboratories were combined. It would appear from the data that the empirical use of amoxicillin-metronidazole combination therapy may be more clinically sound and cost effective than culturing and antibiotic selection based on the results of culture from any single microbiologic testing laboratory.

Screening for cervical cancer in HIV-infected women receiving care in the United States.

OBJECTIVE: We examined the sociodemographic, clinical and provider factors associated with screening for cervical cancer among HIV-infected women. METHODS: We studied a national sample representing 43,490 women receiving treatment of HIV infection who completed first follow-up surveys of the HIV Cost and Service Utilization Study (HCSUS). All women were asked, "In the past 12 months, have you had a Pap test?" Women reporting an abnormal Pap test result were asked whether they had been told antibiotics could cure abnormal cells, and whether they were scheduled for another Pap test or for a colposcopy within 3 months. RESULTS: Of the population represented, 81% had had a Pap test in the past 12 months. Women who reported having a gynecologist and primary care physician at the same clinical site were almost twice as likely (odds ratio, 1.9; 95% confidence interval, 1.3-3.0) as other women to report Pap testing. Among women who reported abnormal Pap test results and were not told antibiotics could cure abnormal cells, 95% were scheduled for a repeat Pap test or colposcopy, but 15% of the women had not received their repeat Pap test or colposcopy. CONCLUSION: Although Pap test rates and appropriate referral for abnormal findings were high among HIV-tested women, many women with initially abnormal Pap test results did not actually receive follow-up Pap testing or colposcopy. Providing gynecologic care at the same site as primary HIV care would likely improve delivery of needed gynecologic care for women.

Injection drug users: hospital care and charges.

Injection drug users have high rates of hospital use, however, the specific contribution of injection-related infections to hospitalization has never been determined. After reviewing 92 consecutive admissions of HIV-negative injection drug users to Rhode Island Hospital in 1998, we found that 49% were related to infections and an additional 24% were due to the biological effects of the injected drug. Admissions that were for injection-related infections were significantly more costly than other admissions of injection drug users ($13958 vs. $7906). We conclude that considerable savings may result from preventative care of this population, including instruction in skin-cleaning techniques.

Linkage to medical services in the Drug Abuse Treatment Outcome Study.

BACKGROUND: An episode of substance abuse treatment is an opportunity to link substance-abusing patients to medical care at a time when management of medical problems might stabilize recovery and long-term health. However, little is known about the ability of organizational linkage mechanisms to facilitate the delivery of medical care to this population. OBJECTIVES: The goal of this study was to examine whether organizational linkage mechanisms facilitate medical service utilization in drug abuse treatment programs. RESEARCH DESIGN: This was a prospective secondary analysis of the Drug Abuse Treatment Outcome Study, a national longitudinal study of drug abuse treatment programs and their patients from 1991 to 1993. Hierarchical linear models evaluated the effect of on-site delivery, formal and informal referral, case management emphasis, and transportation on the log-transformed number of medical visits at the 1-month in-treatment patient interview. MEASURES: Program directors' surveys provided organizational information, including the linkage mechanism used to deliver medical care. Patients reported the number of medical visits during the first month of drug abuse treatment. RESULTS: Exclusive on-site delivery increased medical utilization during the first month of drug abuse treatment (beta estimate, 0.22; standard error [SE], 0.06; P <0.001). Transportation services also increased 1-month medical utilization (beta estimate, 0.13; SE, 0.03; P <0.001). CONCLUSIONS: Exclusive on-site delivery of medical services increased drug abuse treatment patients' utilization of medical services in the first month of treatment. Transportation assistance warrants strong policy consideration as a facilitator of medical service delivery. Future research should clarify whether program-level linkage to medical services improves the patient-level outcomes of drug abuse treatment.

Delays in seeking HIV care due to competing caregiver responsibilities.

OBJECTIVES: This study sought to describe the characteristics of HIV-infected persons who delay medical care for themselves because they are caring for others. METHODS: HIV-infected adults (n = 2864) enrolled in the HIV Cost and Services Utilization Study (1996-1997) were interviewed. RESULTS: The odds were 1.6 times greater for women than for men to put off care (95% confidence interval [CI] = 1.2, 2.2); persons without insurance and with CD4 cell counts above 500 were also significantly more likely to put off care. Having a child in the household was associated with putting off care (odds ratio [OR] = 1.8, 95% CI = 1.4, 2.3). CONCLUSIONS: Women or individuals with a child in the household should be offered services that might allow them to avoid delays in seeking their own medical care.

Prevalence and predictors of unmet need for supportive services among HIV-infected persons: impact of case management.

BACKGROUND: Previous research has indicated that the needs of persons infected with human immunodeficiency virus (HIV) for supportive services often go unmet. Although case management has been advocated as a method of decreasing unmet needs for supportive services, its effectiveness is poorly understood. OBJECTIVES: To assess the prevalence of need and unmet need for supportive services and the impact of case managers on unmet need among HIV-infected persons. RESEARCH DESIGN: National probability sample. PARTICIPANTS: A total of 2,832 HIV-infected adults receiving care. MEASURES: Need and unmet need for benefits advocacy, housing, home health, emotional counseling, and substance abuse treatment services. RESULTS: Sixty-seven percent of the sample had a need for at least one supportive service, and 26.6% had an unmet need for at least one service in the previous 6 months. Contingent unmet need (unmet need among persons who needed the service) was greatest for benefits advocacy (34.6%) and substance abuse treatment (27.6%). Fifty-seven percent of the sample had had contact with their case manager in the previous 6 months. In multiple logistic regression analysis, with adjustment for covariates, having a case manager was associated with decreased unmet need for home healthcare (OR =0.39; 95% CI = 0.25-0.60), emotional counseling (OR = 0.54; 95% CI = 0.38-0.78), and any unmet need (OR = 0.70; 95% CI = 0.54-0.91). An increased number of contacts with a case manager was significantly associated with lower unmet need for home health care, emotional counseling, and any unmet need. CONCLUSIONS: Need and unmet need for supportive services among HIV-infected persons is high. Case management programs appear to lower unmet need for supportive services.

The impact of competing subsistence needs and barriers on access to medical care for persons with human immunodeficiency virus receiving care in the United States.

OBJECTIVES: To examine whether competing subsistence needs and other barriers are associated with poorer access to medical care among persons infected with human immunodeficiency virus (HIV), using self-reported data. DESIGN: Survey of a nationally representative sample of 2,864 adults receiving HIV care. MAIN INDEPENDENT VARIABLES: Going without care because of needing the money for food, clothing, or housing; postponing care because of not having transportation; not being able to get out of work; and being too sick. MAIN OUTCOME MEASURES: Having fewer than three physician visits in the previous 6 months, visiting an emergency room without being hospitalized; never receiving antiretroviral agents, no prophylaxis for Pneumocystis carinii pneumonia in the previous 6 months for persons at risk, and low overall reported access on a six-item scale. RESULTS: More than one third of persons (representing >83,000 persons nationally) went without or postponed care for one of the four reasons we studied. In multiple logistic regression analysis, having any one or more of the four competing needs independent variables was associated with significantly greater odds of visiting an emergency room without hospitalization, never receiving antiretroviral agents, and having low overall reported access. CONCLUSIONS: Competing subsistence needs and other barriers are prevalent among persons receiving care for HIV in the United States, and they act as potent constraints to the receipt of needed medical care. For persons infected with HIV to benefit more fully from recent advances in medical therapy, policy makers may need to address nonmedical needs such as food, clothing, and housing as well as transportation, home care, and employment support.

Economic effects of community versus hospital-based faculty pneumonia care.

To compare the length of stay and charges for patients with pneumonia admitted in 1995 to the teaching and nonteaching services of a Northeastern teaching hospital, we reviewed the charts of 237 patients. Patients cared for by hospital-based generalists working with housestaff (teaching service) were discharged more quickly and with lower or equivalent charges than patients cared for by community-based attending physicians working either with housestaff (private teaching service) or alone (nonteaching service). Academic teaching services staffed by general medicine faculty may provide efficient inpatient pneumonia care.

Use of mental health services by HIV-infected women.

In this study, the first to examine the use of mental health services among a large cohort of HIV-positive women, our objective was to quantify the use of such services by infected women enrolled at one site of the HIV Epidemiology Research Study and to describe the factors associated with such use. One hundred sixty-seven HIV-seropositive women and 67 seronegative women were interviewed between March and November 1995 during their semiannual study visit. Women were asked to report visits they had made to mental health counselors (psychiatrists, social workers, or psychologists) or HIV support groups and any psychiatric hospitalizations during the previous 6 months. About half the seropositive women had a history of injection drug use, were Caucasian, and lived with children, three quarters were insured, and one third were church members. A minority of seropositive women (38%) sought at least one outpatient mental health visit, and 4% had been hospitalized during the previous 6 months. Being a member of a church, having a high school education, and being Caucasian were significantly associated (p < 0.05) with seeing a mental health counselor. Among HIV-positive women who reported at least one visit, their CD4 cell count was the only factor associated with the number of mental health visits. Only 13% of women had attended an HIV support group. Among seronegative women, 27% had at least one outpatient mental health visit during the preceding 6 months. The use of mental health services by women with HIV has economic, not just therapeutic, implications for all HIV service delivery systems.

Use of the ED as a regular source of care: associated factors beyond lack of health insurance.

STUDY OBJECTIVE: To determine the characteristics and health care experiences of patients who identify the ED as their usual source of care. METHODS: We conducted a cross-sectional survey in a Level I trauma center ED at an urban teaching hospital. Our population comprised 892 adults who presented to the ED over the course of 30 days. We asked participants about their regular source of health care, previous health care experiences, and perceptions of the use of the ED. RESULTS: Patients who reported the ED as their regular source of care were three times more likely to have used the ED more than once in the preceding year. Among the regular ED users, 68% desired a physician as their regular source of care, and 46% of these subjects said they had tried unsuccessfully to get one in the preceding year. Five variables were associated with self-report of the ED as the regular source of health care: annual income less than $30,000, having been refused care in an office or clinic in the past, perception that an ED visit costs less than an office visit, absence of chronic illness, and unwillingness to use the ED if a $25 copayment were in effect. CONCLUSION: Low income, perceived mistreatment by health care providers, and misperception about charges contribute to use of the ED as a regular site for health care. These factors suggest the difficulty of altering health care use patterns in this group.

"Inappropriate" emergency department use: a comparison of three methodologies for identification.

OBJECTIVE: To determine the level of agreement between the rates of "inappropriate" ED visits assigned to a cohort of ambulatory patients based on three methods of defining ED use appropriateness. METHODS: Ambulatory adult patients seen at one urban, university-based teaching hospital ED between 8 AM and midnight during select days from April to June 1994 were assessed regarding the appropriateness of their ED visits. Patients triaged to acute resuscitation rooms in the ED were excluded. Eligible patients were asked to complete a 90-question survey including demographics and health service use (response rate 81%). The appropriateness of ED use was assessed for consenting respondents by 1) application of a list of 51 non-emergent complaints that have been used by managed care providers and previously published (TRIAGE), 2) use of ten explicit criteria (e.g., need for parenteral medication) from prior publications (EXPLICIT), and 3) the consensus of two emergency physicians (EPs) reviewing the records of ED patients (PHYS). All three methods were applied at the time of retrospective chart review. The agreement between methods was evaluated using kappa scores. RESULTS: Of the 892 eligible respondents, 64% were white, 54% were employed, 50% were female, and 29% were uninsured. Of the respondents, 26% had no regular source of ambulatory care and 25% considered the ED their regular source of care. The assigned rates of "inappropriate" visits using the three definitions were TRIAGE, 58%; PHYS, 47%; and EXPLICIT, 42%. Of those deemed "inappropriate" by the EXPLICIT criteria, 81% also were judged as "inappropriate" by the TRIAGE criteria, and 72%, by the PHYS criteria. Of those patients deemed "inappropriate" by the TRIAGE criteria, 59% also were judged as "inappropriate" by the EXPLICIT criteria, and 66%, by the PHYS criteria. Levels of agreement (kappas) were TRIAGE/EXPLICIT, 0.39; TRIAGE/PHYS, 0.42; and EXPLICIT/PHYS, 0.42. CONCLUSION: There is only moderate agreement between different methods of determining appropriateness of ED use. Until further refinement is made in triage assessment, managed care organizations and EPs should remain cautious when implementing a protocol that defines and restricts "inappropriate" ED visits.

Injected-drug use: complications and costs in the care of hospitalized HIV-infected patients.

The aim of this study was to determine the contribution of injected-drug-use complications to the utilization of inpatient care by persons infected with human immunodeficiency virus (HIV). Retrospective chart review was done of all hospital admissions between January 1, 1991, and December 31, 1991, with outpatient records reviewed to establish CD4 counts within 3 months of the date of admission. The participants included 284 consecutive admissions (189 patients); admissions were divided into two groups according to the Center for Disease Control 1993 expanded AIDS definition: those with AIDS (CD4 count, < 200 cells/microliters) and those with early HIV disease (CD4 count, > 200 cells/microliters). Thirty percent of admissions occurred among persons with early HIV disease. Among 189 individuals admitted to the hospital, 84% were male, 62% were white, and 48% had injected drugs. Early HIV disease admissions were more likely to involve active injection-drug users (82% vs. 33%; p < 0.01). Admissions related to injected-drug use constituted 60% of early HIV disease hospitalizations, and this number rises to 72% if bacterial pneumonia is included as a substance abuse complication. Admissions related to injected-drug use constituted 27% of AIDS admissions; this number rises to 51% if bacterial pneumonia is included. Early HIV disease admissions were significantly shorter (9.9 vs. 12.6 days) and less expensive (mean charge, $9,592 vs. 12,873) than AIDS admissions but still accounted for 25% of inpatient HIV charges. Hospitalizations among HIV-infected persons early in the course of HIV disease are most often related to the medical complications of injected-drug use and account for a substantial expenditure of hospital resources.(ABSTRACT TRUNCATED AT 250 WORDS)

Who pays for published research?

OBJECTIVE: To determine the extent of unfunded research published in major medical journals. DESIGN: Review of original research completed in the United States and published in 23 official journals of internal medicine and neurology during 1 month in 1991. Investigators were contacted to confirm lack of funding. MAIN OUTCOME MEASURE: Percentage of unfunded, published original research. RESULTS: One hundred ninety-six articles were evaluated. There was at least one unfunded study in 78% of journals. Forty-five published studies (23%) were unfunded. Among those 45 studies, 7% were clinical trials, 9% were cohort studies, 18% were cross-sectional or case-control studies, 53% were case series, and 13% were surveys. Thirteen unfunded studies involved procedures that presumably were performed for research purposes and not as part of routine patient care. CONCLUSIONS: Nearly one quarter of original research published in major medical journals was unfunded. Seven percent of published research involved direct clinical costs that were not accounted for by the investigators. These costs may have been passed on to study participants or third-party payers.

Perceived needs and unmet needs for formal services among people with HIV disease.

This study presents estimates of the prevalence of perceived needs and unmet needs among people with HIV disease in the United States for six areas of community services: mental health, drug treatment, home care, housing, transportation, and entitlements. The prevalence of service needs and unmet needs within racial, gender, drug use history, and other subgroups was also examined. The study is based on a nonrandom cross-sectional sample of 907 people with HIV disease interviewed between November 1988 and May 1989 in nine major urban areas of the United States. Respondents reported high levels of need and unmet need across a variety of service areas. One third or more of all respondents reported a need for mental health services (57%), housing (39%), entitlements (34%), and transportation (32%). Within each of the six service areas, 40% or more reported unmet need. Women, people of color, and injected drug users were more likely to report unmet service need in a number of areas. Given the limitations of the sampling and the focus on current needs, these estimates may represent a lower bound on the magnitude of service need and unmet need within this population.

Differences in access to zidovudine (AZT) among symptomatic HIV-infected persons.

OBJECT: To evaluate socioeconomic factors that determine whether symptomatic HIV-infected persons are offered zidovudine (AZT). DESIGN: Cross-sectional survey conducted as part of the Robert Wood Johnson Foundation's AIDS Health Services Program. SETTING: Public hospital clinics and community-based AIDS organizations in nine American cities. PATIENTS: 880 HIV-seropositive outpatients interviewed between October 1988 and May 1989. MAIN RESULTS: Males were more likely to have been offered AZT than were females (adjusted odds ratio 2.99; 95% confidence interval 1.67 to 5.36), those with insurance were more likely to have been offered AZT than were those without (adjusted odds ratio 2.00; 95% confidence interval 1.25 to 3.21), and whites more likely to have been offered AZT than were non-whites (adjusted odds ratio 1.73; 95% confidence interval 1.11 to 2.69). Intravenous drug users were less likely to have been offered AZT than were non-drug users (adjusted odds ratio 0.44; 95% confidence interval 0.28 to 0.69). Persons who had had an episode of Pneumocystis carinii pneumonia were more likely to have been offered AZT than were persons who had AIDS and had not had Pneumocystis carinii pneumonia (adjusted odds ratio 2.95; 95% confidence interval 1.71 to 5.11). CONCLUSION: The authors conclude that traditionally disadvantaged groups have less access to AZT, the only antiretroviral agent demonstrated to increase survival of patients who have symptomatic HIV infection.