HepCCATT: a multilevel intervention for hepatitis C among vulnerable populations in Chicago.

BACKGROUND: Hepatitis C infection could be eliminated. Underdiagnosis and lack of treatment are the barriers to cure, especially for vulnerable populations (i.e. unable to pay for health care). METHODS: A multilevel intervention from September 2014 to September 2019 focused on the providers and organizations in 'the safety net' (providing health care to populations unable to pay), including: (i) public education, (ii) training for primary care providers (PCPs) and case managers, (iii) case management for high-risk populations, (iv) policy advice and (v) a registry (Registry) for 13 health centers contributing data. The project tracked the number of PCPs trained and, among Registry sites, the number of people screened, engaged in care (i.e. clinical follow-up after diagnosis), treated and/or cured. RESULTS: In Chicago, 215 prescribing PCPs and 56 other health professionals, 86% of whom work in the safety net, were trained to manage hepatitis C. Among Registry sites, there was a 137% increase in antibody screening and a 32% increase in current hepatitis C diagnoses. Engagement in care rose by 18%. CONCLUSIONS: Hepatitis C Community Alliance to Test and Treat (HepCCATT) successfully targeted safety net providers and organizations with a comprehensive care approach. While there were challenges, HepCCATT observed increased hepatitis C screening, diagnosis and engagement in care in the Chicago community.

Disparities in Elevated Body Mass Index in Youth Receiving Care at Community Health Centers.

Childhood obesity has increased significantly in the United States. Racial subgroups are often grouped into categories in research, limiting our understanding of disparities. This study describes the prevalence of obesity among youth of diverse racial and ethnic backgrounds receiving care at community health centers (CHCs). This cross-sectional study describes the prevalence of elevated body mass index (BMI) (≥85th percentile) and obesity (≥95th percentile) in youth aged 9 to 19 years receiving care in CHCs in 2014. Multilevel logistic regression estimated the prevalence of elevated BMI and obesity by age, race/ethnicity, and sex. Among 64 925 youth, 40% had elevated BMI and 22% were obese. By race, obesity was lowest in the combined Asian/Pacific Islander category (13%); however, when subgroups were separated, the highest prevalence was among Native Hawaiians (33%) and Other Pacific Islanders (42%) and the lowest in Asians. By sex, Black females and Hispanic and Asian males were more likely to be obese. By age, the highest prevalence of obesity was among those aged 9 to 10 years (25%). Youth served by CHCs have a high prevalence of obesity, with significant differences observed by race, sex, and age. Combining race categories obscures disparities. The heterogeneity of communities warrants research that describes different populations to address obesity.

Cervical intraepithelial neoplasia and cancer in women 35 years and older.

OBJECTIVE: To evaluate the distribution of abnormal cytohistopathology among low-income women 35 years and older compared with women younger than 35 years. MATERIALS AND METHODS: This was a retrospective analysis of the 896 women who presented to the dysplasia clinic at an urban, public, tertiary care hospital with abnormal cervical cytology from September 23, 2008, to September 23, 2010. Statistical comparisons were made using t, χ(2), and Wilcoxon rank sum tests. RESULTS: Of the 896 patients, 460 (51%) were aged 35 years or older. Among the women 35 years and older, 56% had negative/benign histologic findings compared with 45% in women younger than 35 years. Conversely, women 35 years and older had lower rates of cervical intraepithelial neoplasia 1 (14%) than women younger than 35 years (30%). However, the prevalence of cancer diagnosis, per colposcopy, increased significantly with age, affecting 6% of women aged 50 years or older, 2% of women aged 35 to 49 years, and 1% of women younger than 35 years (p = .0008). CONCLUSIONS: Women older than 35 years with abnormal cytology demonstrated increased severity of cervical intraepithelial neoplasia on histology compared with younger women. Although women younger than 35 years were more likely to have transient human papillomavirus infections, a very high prevalence of severe cervical intraepithelial neoplasia and cancer was identified among women aged 35 years and older. Careful evaluation and follow-up must be performed for this group of women who may have previously been considered by some clinicians to be low risk on the basis of their age.

Barriers to Healthcare and Social Service Utilization Among Rural Older Adults Who Use Drugs.

The objective of this study was to understand barriers to healthcare and social service utilization among older adults residing in rural areas who use drugs. A cross-sectional survey of persons who use opioids or inject drugs in rural counties with high overdose rates across ten states was conducted. For this analysis, participants were restricted to only the 375 individuals aged 50 and older. They were asked about barriers to utilizing healthcare and social services. Multivariate analyses were conducted. The most common barriers were a lack of transportation and a fear of stigma. The average number of barriers was 2.53. Those who were either uninsured or homeless endorsed 37% more barriers. For every five-year increase in age, the number of barriers reduced by 15%. Efforts to reduce these barriers may include expanding eligibility for transportation and housing services and leveraging trusted community members to broker linkages to providers to overcome stigma.

Erratum: Sociome Data Commons: A scalable and sustainable platform for investigating the full social context and determinants of health - ERRATUM.

[This corrects the article DOI: 10.1017/cts.2023.670.].

Impact of an Urban Project ECHO: Safety-Net Clinician Self-Efficacy Across Conditions.

INTRODUCTION: To mitigate the lack of specialty healthcare, Project ECHO (Extension for Community Health Outcomes) trains community-based primary care clinicians to better prevent the progression of, manage, and treat common health conditions. ECHO-Chicago launched in 2010 as the first urban-centered ECHO program, focusing on safety-net clinicians, and has trained over 5,175 community clinicians across 34 topic areas. This paper examines self-efficacy among ECHO-Chicago participants across 11 clinical series, including a novel use of qualitative themes from self-efficacy questions. METHODS: Five years of baseline and postseries survey data were collected from 2014 to 2019, resulting in 951 participants. Paired t-tests assessed change from baseline survey to postsurvey, and Cohen's d determined effect size. Change was assessed by individual series, adult or pediatric focus, participants' prescription privilege status, and across series by qualitative question theme. Metrics included total change, any improvement, a 10% target, and a clinical competency threshold. Analysis occurred from July 2020 to January 2022. RESULTS: All clinical series achieved statistically significant improvement in self-efficacy, and most had a large effect size. A total of 88% had any improvement, 65% met the 10% target of 0.7 points, and 52% met the competency threshold of 5.0 in the postsurvey. Prescribers had a significantly greater increase in their self-efficacy scores than nonprescribers. With a comparison across series, each theme achieved statistical significance, with most reaching large effect sizes. CONCLUSIONS: ECHO-Chicago successfully increased participants' self-efficacy. This inquiry adds an urban focus, years of data, multiple series, and a novel qualitative theme component to enable comparisons across rather than solely within the ECHO series.

Sociome Data Commons: A scalable and sustainable platform for investigating the full social context and determinants of health.

Background/Objective: Non-clinical aspects of life, such as social, environmental, behavioral, psychological, and economic factors, what we call the sociome, play significant roles in shaping patient health and health outcomes. This paper introduces the Sociome Data Commons (SDC), a new research platform that enables large-scale data analysis for investigating such factors. Methods: This platform focuses on "hyper-local" data, i.e., at the neighborhood or point level, a geospatial scale of data not adequately considered in existing tools and projects. We enumerate key insights gained regarding data quality standards, data governance, and organizational structure for long-term project sustainability. A pilot use case investigating sociome factors associated with asthma exacerbations in children residing on the South Side of Chicago used machine learning and six SDC datasets. Results: The pilot use case reveals one dominant spatial cluster for asthma exacerbations and important roles of housing conditions and cost, proximity to Superfund pollution sites, urban flooding, violent crime, lack of insurance, and a poverty index. Conclusion: The SDC has been purposefully designed to support and encourage extension of the platform into new data sets as well as the continued development, refinement, and adoption of standards for dataset quality, dataset inclusion, metadata annotation, and data access/governance. The asthma pilot has served as the first driver use case and demonstrates promise for future investigation into the sociome and clinical outcomes. Additional projects will be selected, in part for their ability to exercise and grow the capacity of the SDC to meet its ambitious goals.

Emergency contraception after sexual assault: changes in provision from 2004 to 2009.

OBJECTIVE: A random sample (20%) of U.S. and territorial emergency departments were surveyed in 2004 and again in 2009 to obtain information about provision and counseling of emergency contraception (EC) to sexual assault victims. STUDY DESIGN: A representative sample of 20% of hospitals, stratified by state/ territory was prepared from the American Hospital Association list in order to conduct a 13-question telephone survey. Questions included (1) "Is there a written protocol for counseling about EC for sexual assault victims?" (2) "Are sexual assault victims at risk of pregnancy counseled about EC?" and (3) "Are sexual assault victims at risk of pregnancy provided EC?" A cross-sectional prevalence survey was administered in 2004 and 2009. RESULTS: Provision of EC has changed very little from 2004 to 2009 (63% vs. 64%, respectively). Provision varies by number of victims treated, region of country and status of state legislation. CONCLUSION: Prophylaxis against possible pregnancy is an important part of sexual assault treatment and should be maximized. EC provision for sexual assault victims in emergency departments has not greatly increased over time and does not reflect regulatory changes in accessibility. Prophylaxes against sexually transmitted infections and pregnancy are handled differently for sexual assault victims, reflecting distinct separation of sexual and reproductive health in clinical practice.

Applying Project ECHO (Extension for Community Health Care Outcomes) to improve addiction care in rural emergency departments.

Background: Advancements in research and legislation have improved emergency provider ability to treat opioid use disorder (OUD), but dissemination into rural emergency departments (EDs) is limited. Project Extension for Community Healthcare Outcomes (ECHO) allows community generalists to learn from specialists through telementoring. We aimed to use ECHO to facilitate knowledge translation, increase confidence, and change behavior of rural ED providers treating patients with OUD. Methods: Stakeholder interviews were conducted with rural ED providers. A group of ED addiction experts created an ECHO curriculum with eight OUD topics. ED health professionals were recruited and completed pre/post surveys centered around knowledge and comfort with treating OUD in the ED, with focus on clinical practice and stigma. Following the ECHO model, sessions included a 20-min didactic followed by two cases presented by participants, with discussion facilitated by faculty. Results: Twenty-seven participants registered; seven attended ≥75% of sessions and completed both surveys. Of the seven, three were physicians, two advanced practice providers, one nurse, and one clinical pharmacist. Eight 1-hour sessions were conducted in two cohorts between January and December 2021. On a 5-point Likert scale, respondents on average agreed with questions evaluating acceptability (mean ± SD 3.96 ± 0.64), appropriateness (mean ± SD 4.18 ± 1.18), and feasibility (mean ± SD 4.00 ± 1.17). Participants had a 1.09-point increase (paired t-test = 2.43, p = 0.05) on 7-point Likert-scale questions measuring self-efficacy and a 0.13-point change (paired t-test = 2.64, p = 0.04) on 4-point Likert scale questions measuring stigmatizing attitudes (reduction of attitudes). A total of 71% (5/7) reported changes in clinical practice and 57% (4/7) in departmental protocols after participation. Conclusions: Our ED OUD ECHO course successfully created a model for rural ED providers to learn from ED addiction experts. It was well received and impacted self-reported provider stigmatizing attitudes, patient-facing behavior, and departmental initiatives. Recruitment was challenging and participation was limited. Future efforts will target maximizing recruitment.

Daily context matters: predictors of missed oral contraceptive pills among college and graduate students.

OBJECTIVE: The purpose of this study was to understand the relationship between daily contextual factors and oral contraceptive (OC) adherence among students who attend college or graduate school. STUDY DESIGN: Data on OC adherence, demographics, contextual factors, and side-effects were collected as part of the acceptability of the NuvaRing (Merck & Co, Whitehouse Station, NJ) vs OC study, in which students were assigned randomly to the contraceptive vaginal ring or to a low-dose OC. We performed bivariate and multivariable analyses to create an explanatory model for nonperfect OC adherence (missed at least 1 pill during 3 months of use). RESULTS: In a multivariable predictive model, missing a pill was associated positively with high perceived stress (odds ratio [OR], 3.16; P = .007), having ≥10 hours per week of paid employment (OR, 2.13; P = .075), and living with a partner (OR, 9.92; P = .040). CONCLUSION: Stressful and hectic lives contribute to poor OC adherence. When counseling women about contraception, clinicians should consider the influence of daily life on contraceptive adherence.

Assessing the extent of provision of comprehensive medical care management for female sexual assault patients in US hospital emergency departments.

OBJECTIVE: To describe medical services provided to sexual assault patients in US emergency departments and to identify the percentage of hospitals always providing the 10 elements of comprehensive medical care management (CMCM). METHODS: A cross-sectional study was conducted in a national sample of US hospitals. A 26-item telephone survey assessed provision of services to sexual assault survivors in accordance with CMCM. Management included acute medical care comprising history and physical examination; acute and long-term rape crisis counseling; STI testing and prophylaxis; emergency contraception counseling and provision; and HIV testing and prophylaxis. The primary outcome was extent of provision of these elements. RESULTS: Overall, 582 emergency departments responded to the survey. The following components of CMCM were provided: acute medical care (582 [100.0%]); rape crisis counseling (234 [40.2%]); STI management (448 [77.0%]); emergency contraception (351 [60.3%]); and HIV management (380 [65.3%]). Only 101 (17.4%) hospitals provided all 10 elements of CMCM. CONCLUSION: Less than one-fifth of US hospitals provide comprehensive services to sexual assault patients. A national program incorporating clinical guidelines, checklists, and funding for sexual assault forensic/nurse examiner programs could improve the standard of care provided in emergency departments-the primary point of contact for acute care of sexual assault survivors.

Male subfertility and the role of micronutrient supplementation: clinical and economic issues.

The concept of male subfertility has evolved rapidly since 2000. This term is discussed based upon evidence relating to its first entrance into the literature, along with contemporary references to its purported incidence and prevalence. Factors affecting sperm quality are described in detail, and available data pertaining to the effects of micronutrients on spermatic parameters and resulting pregnancies are described. The first cost-efficiency analysis of the use of micronutrients vs. assisted reproductive technologies is presented. This paper also describes a therapeutic approach to males, recognizing that many potential fathers have no recourse to medical facilities to evaluate their fertility. At a time when medical dollars are either nonexistent or precious, such an approach using micronutrient supplementation may be cost-effective in developing and possibly even in developed countries.

Adherence and acceptability of the contraceptive ring compared with the pill among students: a randomized controlled trial.

OBJECTIVES: To compare satisfaction with and adherence to the contraceptive vaginal ring and a daily low-dose oral contraceptive pill (OCP) among college and graduate students using a novel method of electronic data collection. METHODS: We randomly assigned 273 women to the contraceptive vaginal ring (n=136) or OCP (n=137) for three consecutive menstrual cycles. Participants completed daily Internet-based, online diaries regarding method adherence and satisfaction during cycles of use. At 3 months, they completed an online survey regarding intention to continue their method and overall acceptability. At 6 months, we surveyed participants to see whether they continued using contraception and, if so, which method. RESULTS: Rates of loss to follow-up were similar between groups. Contraceptive vaginal ring users reported more perfect use in the first 2 months (P=.05). After the 3-month study period, 52 (43%) of 121 contraceptive vaginal ring users and 65 (52%) of 126 OCP users reported plans to continue their method (P=.16). However, at 6 months, only 31 (26%) of 117 contraceptive vaginal ring users and 36 (29%) of 123 OCP users had continued their assigned study method (P=.61). Almost 50% of both groups were using condoms or no method. CONCLUSION: Contraceptive vaginal ring users were more likely to report perfect use during the 3-month trial period than were OCP users. Despite randomization, participants were equally satisfied with their assigned hormonal contraceptive method. At 6 months, less than 30% of participants were still using their assigned method. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00635570.