Implementing digital systems to facilitate genetic testing for hereditary cancer syndromes: An observational study of 4 clinical workflows.

PURPOSE: National efforts have prioritized the identification of effective methods for increasing case ascertainment and delivery of evidence-based health care for individuals at elevated risk for hereditary cancers. METHODS: This study examined the uptake of genetic counseling and testing following the use of a digital cancer genetic risk assessment program implemented at 27 health care sites in 10 states using 1 of 4 clinical workflows: (1) traditional referral, (2) point-of-care scheduling, (3) point-of-care counseling/telegenetics, and (4) point-of-care testing. RESULTS: In 2019, 102,542 patients were screened and 33,113 (32%) were identified as at high risk and meeting National Comprehensive Cancer Network genetic testing criteria for hereditary breast and ovarian cancer, Lynch syndrome, or both. Among those identified at high risk, 5147 (16%) proceeded with genetic testing. Genetic counseling uptake was 11% among the sites with workflows that included seeing a genetic counselor before testing, with 88% of patients proceeding with genetic testing after counseling. Uptake of genetic testing across sites varied significantly by clinical workflow (6% referral, 10% point-of-care scheduling, 14% point-of-care counseling/telegenetics, and 35% point-of-care testing, P < .0001). CONCLUSION: Study findings highlight the potential heterogeneity of effectiveness attributable to different care delivery approaches for implementing digital hereditary cancer risk screening programs.

Infectious diseases prevention and control using an integrated health big data system in China.

BACKGROUND: The Yinzhou Center for Disease Prevention and Control (CDC) in China implemented an integrated health big data platform (IHBDP) that pooled health data from healthcare providers to combat the spread of infectious diseases, such as dengue fever and pulmonary tuberculosis (TB), and to identify gaps in vaccination uptake among migrant children. METHODS: IHBDP is composed of medical data from clinics, electronic health records, residents' annual medical checkup and immunization records, as well as administrative data, such as student registries. We programmed IHBDP to automatically scan for and detect dengue and TB carriers, as well as identify migrant children with incomplete immunization according to a comprehensive set of screening criteria developed by public health and medical experts. We compared the effectiveness of the big data screening with existing traditional screening methods. RESULTS: IHBDP successfully identified six cases of dengue out of a pool of 3972 suspected cases, whereas the traditional method only identified four cases (which were also detected by IHBDP). For TB, IHBDP identified 288 suspected cases from a total of 43,521 university students, in which three cases were eventually confirmed to be TB carriers through subsequent follow up CT or T-SPOT.TB tests. As for immunization screenings, IHBDP identified 240 migrant children with incomplete immunization, but the traditional door-to-door screening method only identified 20 ones. CONCLUSIONS: Our study has demonstrated the effectiveness of using IHBDP to detect both acute and chronic infectious disease patients and identify children with incomplete immunization as compared to traditional screening methods.

Principles of Care for Young Adults With Co-Occurring Psychiatric and Substance Use Disorders.

Over 50% of young adults (defined as individuals aged 18-25 years) with substance use disorders (SUDs) have at least 1 co-occurring psychiatric disorder, and the presence of co-occurring disorders worsens SUD outcomes. Treatment of both co-occurring psychiatric disorders and SUDs in young adults is imperative for optimal treatment, yet many barriers exist to achieving this goal. We present a series of evidence-informed principles of care for young adults with co-occurring psychiatric disorders derived by a workgroup of experts convened by Boston Medical Center's Grayken Center for Addiction. The 3 principles are as follows: (1) young adults should receive integrated mental health and addiction care across treatment settings; (2) care should be responsive to the needs of young adults exposed to trauma and other adverse childhood experiences; and (3) treatment programs should regularly assess and respond to the evolving mental health needs, motivations, and treatment goals of young adults with co-occurring disorders. Our guidance for each principle is followed by a review of the evidence supporting that principle, as well as practice considerations for implementation. More research among young adults is critical to identify effective treatments and service systems for those with co-occurring disorders.

Support Services for Young Adults With Substance Use Disorders.

In summarizing the proceedings of a longitudinal meeting of experts in substance use disorders (SUDs) among young adults, this special article reviews principles of care concerning recovery support services for this population. Young adults in recovery from SUDs can benefit from a variety of support services throughout the process of recovery. These services take place in both traditional clinical settings and settings outside the health system, and they can be delivered by a wide variety of nonprofessional and paraprofessional individuals. In this article, we communicate fundamental points related to guidance, evidence, and clinical considerations about 3 basic principles for recovery support services: (1) given their developmental needs, young adults affected by SUDs should have access to a wide variety of recovery support services regardless of the levels of care they need, which could range from early intervention services to medically managed intensive inpatient services; (2) the workforce for addiction services for young adults benefits from the inclusion of individuals with lived experience in addiction; and (3) recovery support services should be integrated to promote recovery most effectively and provide the strongest possible social support.

The Effect of Integrating Primary Care and Mental Health Services on Diabetes and Depression: A Multi-site Impact Evaluation on the US-Mexico Border.

BACKGROUND: Health care delivery systems are increasingly integrating physical and mental health services to address patients' complex needs, contain costs, and improve satisfaction. Therefore, it is critical to understand whether adoption of integrated care models is effective in diverse settings. OBJECTIVE: This study examined the effect of integrated care on physical and mental health outcomes among low-income Latino participants on the US-Mexico border. RESEARCH DESIGN: In this quasi-experimental multisite study, individual-level data were pooled from 8 studies of locally adapted integrated care models. SUBJECTS: Participants were 18 years or older and had 1 or more chronic conditions: diabetes, depression, hypertension, or obesity. The study enrolled 4226 participants with 2254 participants in the intervention group and 1972 in the comparison group. MEASURES: Primary outcomes were depressive symptoms as measured by the Patient Health Questionnaire-9 score and blood glucose measured by hemoglobin A1c (HbA1c). Blood pressure, body mass index, and quality of life were secondary outcomes. RESULTS: Multivariable linear regression analyses indicated intervention participants had significantly lower Patient Health Questionnaire-9 scores (ß=-0.39, P=0.03) and HbA1c (ß=-0.14, P=0.02) at 12 months compared with comparison group participants. Stratified analyses showed improvements in HbA1c were even greater among intervention participants who had diabetes, depression, severe and persistent mental illness, were older or female compared with their counterparts in the comparison group. CONCLUSIONS: Health care is constantly transforming, making it critical to study these changes across populations and settings. Findings from this study indicate that integrated care can significantly improve mental and physical health in an underserved Latino population.

Determinants of non-prescription antibiotic dispensing in Chinese community pharmacies from socio-ecological and health system perspectives.

Although non-prescription antibiotic dispensing (NPAD) has been officially forbidden by the Chinese government since 2004, it is still a common practice throughout the country. In this study, we use China as an example to explore the determinants of NPAD within the framework of its health system from a socio-ecological perspective. A mixed-method combining the simulated client method (SCM) and key informant interviews conducted in Zhejiang, Hubei, and Sichuan provinces was adopted. 73.3% of the SCM interactions engendered NPAD (91.7% through antibiotic requests vs. 55% through consultation) in Chinese community pharmacies; a much higher rate than the global average. At the intrapersonal level, NPAD was found to be driven by profits from selling non-prescription antibiotics and traditional Chinese medicine. At the interpersonal level, NPAD was driven by fierce competition in the community pharmacy market and by customers' unreasonable expectations. At the institutional level, it is easy for community pharmacies to evade the Food and Drug Administration's (FDA) supervision by obtaining unsupervised and fake prescriptions, refusing to give customers sale receipts, and hiding their antibiotic supplies and sale records. At the policy level, the low cost of violating the prescription-only antibiotic sale regulation and poor FDA supervision facilitated NPAD. The Chinese health system has thus failed to establish and regulate a diverse network of pharmacies for patients to fill their prescriptions; few antibiotic prescriptions are transferred from hospitals to community pharmacies. Education campaigns to increase awareness about the risks of self-medication with antibiotics among the general public, recognizable standardize prescriptions for customers to fill their prescriptions in community pharmacies, regulations on Internet and private clinic doctors' antibiotic prescribing behaviors, electronic tracking and tracing system to purchases and sales data of antibiotics and other prescription drugs, increasing cost of violating the prescription-only regulations for antibiotics sales are expected interventions to reduce NPAD.

Randomized Trial of Reverse Colocated Integrated Care on Persons with Severe, Persistent Mental Illness in Southern Texas.

BACKGROUND: Persons with severe, persistent mental illness (SPMI) are at high risk for poor health and premature mortality. Integrating primary care in a mental health center may improve health outcomes in a population with SPMI in a socioeconomically distressed region of the USA. OBJECTIVE: To examine the effects of reverse colocated integrated care on persons with SPMI and co-morbid chronic disease receiving behavioral health services at a local mental health authority located at the US-Mexico border. DESIGN: Randomized trial evaluating the effect of a reverse colocated integrated care intervention among chronically ill adults. PARTICIPANTS: Participants were recruited at a clinic between November 24, 2015, and June 30, 2016. INTERVENTIONS: Receipt of at least two visits with a primary care provider and at least one visit with a chronic care nurse or dietician, compared with usual care (behavioral health only). MAIN MEASURES: The primary outcome was blood pressure. Secondary outcomes included HbA1c, BMI, total cholesterol, and depressive symptoms. Sociodemographic data were collected at baseline, and outcomes were measured at baseline and 6- and 12-month follow-ups. KEY RESULTS: A total of 416 participants were randomized to the intervention (n = 249) or usual care (n = 167). Groups were well balanced on almost all baseline characteristics. At 12 months, intent-to-treat analysis showed intervention participants improved their systolic blood pressure (ß = - 3.86, p = 0.04) and HbA1c (ß = - 0.36, p = 0.001) compared with usual care participants when controlling for age, sex, and other baseline characteristics. No participants withdrew from the study due to adverse effects. Per-protocol analyses yielded similar results to intent-to-treat analyses and found a significantly protective effect on diastolic blood pressure. Older and diabetic populations differentially benefited from this intervention. CONCLUSIONS: Colocation and integration of behavioral health and primary care improved blood pressure and HbA1c after 1-year follow-up for persons with SPMI and co-morbid chronic disease in a US-Mexico border community. TRIAL REGISTRATION: clinicaltrials.gov , Identifier: NCT03881657.

A reverse colocated integrated care model intervention among persons with severe persistent mental illness at the U.S.-Mexico border: A randomized controlled trial protocol.

Persons with severe persistent mental illness (SPMI)-which includes individuals with schizophrenia, bipolar disorder, and mood disorders such as major depression-are at high risk for poor health outcomes and premature death. Persons with SPMI are largely absent from research evaluating innovative health care models due to recruitment and retention barriers. This paper presents the protocol for a randomized control trial testing a reverse colocated integrated care model in an SPMI population receiving care at a mental health clinic at the U.S.-Mexico border. The study employs a randomized control trial design to determine whether reverse colocated integrated care improves physical and mental health of persons with SPMI. Participants will be randomized to receive the integrated primary care intervention or usual care (behavioral health only). All study participants will complete baseline, 6-, and 12-month assessments. Study outcomes included blood pressure, HbA1c, cholesterol, body mass index, depression, and adult functioning. Despite challenges in recruiting and retaining SPMI patients, co-locating primary care services within a local mental health authority has the potential to improve health and reduce health disparities experienced by persons with SPMI. The study will determine the impacts of this colocated integrated care model among SPMI patients in a socio-economically disadvantaged region. Clinical Trials.gov Identifier: NCT03881657.