Evaluating outpatient diagnostic stewardship of comprehensive polymerase chain reaction Clostridioides difficile testing in a regional health system.

Objective: We examined the use of comprehensive and targeted polymerase chain reaction (PCR) of Clostridioides difficile infection (CDI) among immunocompetent patients with and without CDI risk factors across different outpatient settings. A priori, we expected patients with higher CDI risk to be associated with targeted testing to reflect providers incorporating pretest risk factors in their choice of test assay. Design: Retrospective analysis of adult patients from clinic, emergency room, and non-medically acute inpatient settings. Setting: A tertiary academic medical center offering inpatient and outpatient medical, surgical, mental health, and rehabilitation services to Veterans across the Puget Sound region. Patients: Immunocompetent adult patients with ≥1 stool PCR assay performed between January 2016 and December 2019. Intervention: Patients were tested with either a specific tcdB PCR assay or a comprehensive gastrointestinal PCR panel that tests for 22 pathogens. Results: A total of 2,717 tests (74% targeted, 26% comprehensive) were obtained from 2,156 patients, among which 13% detected C. difficile and 7% detected other organisms. The proportion of comprehensive PCR tests increased nearly four-fold from 2016 to 2019 in clinic and emergency room settings, independent of CDI risk factors. Only two CDI risk factors (prior history of CDI and antibiotic use within three months before testing) were associated with increased targeted testing. Conclusion: The use of comprehensive GI PCR among immunocompetent adults with diarrhea is increasing in the outpatient setting. There may be an opportunity for diagnostic stewardship by nudging providers to consider all CDI risk factors at the time of test selection.

Two decades of diabetes prevention efforts: A call to innovate and revitalize our approach to lifestyle change.

The impact of global diabetes prevention efforts has been modest despite the promise of landmark diabetes prevention trials nearly twenty years ago. While national and regional initiatives show potential, challenges remain to adapt large-scale strategies in the real-world that fits individuals and their communities. Additionally, the sedentary lifestyle changes during the COVID-19 pandemic and guidelines that now call for earlier screening (e.g., US Preventative Task Force) will increase the pool of eligible adults worldwide. Thus, a more adaptable, person-centered approach that expands the current toolkit is urgently needed to innovate and revitalize our approach to diabetes prevention. This review identifies key priorities to optimize the population-level delivery of diabetes prevention based on a consensus-based evaluation of the current evidence among experts in global translational programs; key priorities identified include (1) participant eligibility, (2) intervention intensity, (3) delivery components, (4) behavioral economics, (5) technology, and (6) the role of pharmacotherapy. We offer a conceptual framework for a broader, person-centered approach to better address an individual's risk, readiness, barriers, and digital competency.

Reach, engagement and effectiveness of in-person and online lifestyle change programs to prevent diabetes.

BACKGROUND: COVID-19 has accelerated interest in and need for online delivery of healthcare. We examined the reach, engagement and effectiveness of online delivery of lifestyle change programs (LCP) modelled after the Diabetes Prevention Program (DPP) in a multistate, real-world setting. METHODS: Longitudinal, non-randomized study comparing online and in-person LCP in a large multistate sample delivered over 1 year. Sample included at-risk adults (n = 26,743) referred to online (n = 9) and in-person (n = 11) CDC-recognized LCP from a multi-state registry (California, Florida and Colorado) between 2015 and 2018. The main outcome was effectiveness (proportion achieving > 5% weight loss) at one-year. Our secondary outcomes included reach (proportion enrolled among referred) and engagement (proportion ≥ 9 sessions by week 26). We used logistic regression modelling to assess the association between participant- and setting -level characteristics with meaningful weight loss. RESULTS: Online LCP effectiveness was lower, with 23% of online participants achieving > 5% weight loss, compared with 35% of in-person participants (p < 0.001). More adults referred to online programs enrolled (56% vs 51%, p < 0.001), but fewer engaged at 6-months (attendance at ≥9 sessions 46% vs 66%, p < 0.001) compared to in-person participants. CONCLUSIONS: Compared to adults referred to in-person LCP, those referred to online LCP were more likely to enroll and less likely to engage. Online participants achieved modest meaningful weight loss. Online delivery of LCP is an attractive strategy to deliver and scale DPP, particularly with social distancing measures currently in place. However, it is unclear how to optimize delivery models for maximal impact given trade-offs in reach and effectiveness.

Food Insecurity May Be an Independent Risk Factor Associated with Nonalcoholic Fatty Liver Disease among Low-Income Adults in the United States.

BACKGROUND: Nonalcoholic fatty liver disease (NAFLD), considered a "barometer" of metabolic health, is the leading cause of liver disease in the United States. Despite established associations between food insecurity and obesity, hypertension, and diabetes, little is known about the relation between food insecurity and NAFLD. OBJECTIVE: We sought to evaluate the association of food insecurity with NAFLD among low-income adults in the United States. METHODS: We conducted a cross-sectional analysis of a nationally representative sample of adults from the NHANES (2005-2014 waves). Participants included adults in low-income households (≤200% of the federal poverty level) without chronic viral hepatitis or self-reported heavy alcohol use. Food insecurity was measured using the Household Food Security Survey. Our primary outcome was NAFLD, as estimated by the US Fatty Liver Index, and our secondary outcome was advanced fibrosis, as estimated by the NAFLD fibrosis score. The association between food insecurity (defined as low and very low food security) and hepatic outcomes was assessed using multivariable logistic regression, adjusting for sociodemographic factors. RESULTS: Among 2627 adults included in the analysis, 29% (95% CI: 26%, 32%) were food insecure. The median age was 43 y, 58% were female, and 54% were white. The weighted estimated prevalence of NAFLD did not differ significantly by food security status (food secure 31% compared with food insecure 34%, P = 0.21). In the multivariable model, food-insecure adults were more likely to have NAFLD (adjusted OR: 1.38; 95% CI: 1.08, 1.77) and advanced fibrosis (adjusted OR: 2.20; 95% CI: 1.27, 3.82) compared with food-secure adults. CONCLUSIONS: Food insecurity may be independently associated with NAFLD and advanced fibrosis among low-income adults in the United States. Future strategies should assess whether improved food access, quality, and healthy eating habits will decrease the growing burden of NAFLD-associated morbidity and mortality among at-risk adults.

Costs and cost-effectiveness of HIV/noncommunicable disease integration in Africa: from theory to practice.

: The current article reviews economic aspects of selected HIV/noncommunicable disease (NCD) service delivery integration programs to assess the efficiency of integration in limited capacity settings. We define economies of scope and scale and their relevance to HIV/NCD integration. We summarize the results of a systematic review of cost and cost-effectiveness studies of integrated care, which identified 12 datasets (nine studies) with a wide range of findings driven by differences in research questions, study methods, and health conditions measured. All studies were done in Africa and examined screening interventions only. No studies assessed the cost of integrated, long-term disease management. Few studies estimated the cost-effectiveness of integrated screening programs. The additional cost of integrating NCD screening with HIV care platforms represented a 6-30% increase in the total costs of the programs for noncancer NCDs, with cervical cancer screening costs dependent on screening strategy. We conducted 11 key informant interviews to uncover perceptions of the economics of HIV/NCD integration. None of the informants had hard information about the economic efficiency of integration. Most expected integrated care to be more cost-effective than current practice, though a minority thought that greater specialization could be more cost-effective. In the final section of this article, we summarize research needs and propose a 'minimum economic dataset' for future studies. We conclude that, although integrated HIV/NCD care has many benefits, the economic justification is unproven. Better information on the cost, cost-effectiveness, and fiscal sustainability of integrated programs is needed to justify this approach in limited-resource countries.

Cost of Integrating Noncommunicable Disease Screening Into Home-Based HIV Testing and Counseling in South Africa.

INTRODUCTION: Integrated HIV-noncommunicable disease (NCD) services have the potential to avert death and disability but require data on program costs to assess the impact of integrated services on affordability. METHODS: We estimated the incremental costs of NCD screening as part of home-based HIV testing and counseling (HTC) and referral to care in KwaZulu-Natal, South Africa. All adults in the households were offered integrated HIV-NCD screening (for HIV, diabetes, hypertension, hypercholesterolemia, obesity, depression, tobacco, and alcohol use), counseling, and linkage to care. We conducted comprehensive program microcosting including ingredient-based and activity-based costing, staff interviews, and time assessment studies. Sensitivity analyses varied cost inputs and screening efficiency. RESULTS: Integrating all-inclusive NCD screening as part of home-based HTC in a high HIV prevalence setting increased program costs by $3.95 (42%) per person screened (from $9.36 to $13.31 per person). Integrated NCD screening, excluding point-of-care cholesterol testing, increased program costs by $2.24 (24%). Furthermore, NCD screening integrated into HTC services reduced the number of persons tested by 15%-20% per day. CONCLUSIONS: Integrated HIV-NCD screening has the potential to efficiently use resources compared with stand-alone services. Although all-inclusive NCD screening could increase the incremental cost per person screened for integrated HIV-NCD services over 40%, a less costly lipid assay or targeted screening would result in a modest increase in costs with the potential to avert NCD death and disability. Our analysis highlights the need for implementation science studies to estimate the cost-effectiveness of integrated HIV-NCD screening and linkage per disability-adjusted life year and death averted.

Effectiveness of a clinic-based colorectal cancer screening promotion program for underserved Hispanics.

BACKGROUND: Hispanics in the United States are less likely than other groups to receive screening services for colorectal cancer. METHODS: The authors conducted a clinic-based individual randomized trial that enrolled Hispanic patients ages 50 to 79 years who had been seen in the Seattle-based community clinic in the past 5 years. A total of 501 patients met the eligibility criteria and were randomized to 1 of 3 conditions: 1) usual care; 2) mailed fecal occult blood test (FOBT) card and instructions on how to complete the test (mailed FOBT only); and 3) mailed FOBT card and instructions on how to complete the test, telephone reminders, and home visits (mailed FOBT and outreach). The authors assessed postintervention differences in rates of FOBT screening in intervention and usual care groups using computerized medical records reviewed from June 2007 to March 2008. RESULTS: Data analysis occurred between November 2008 and September 2009. Nine-month postintervention screening rates were 26% among patients who received the mailed packet only intervention (P < .001 compared with usual care) and 31% in the group that received the mailed packet and outreach intervention (P < .001 compared with usual care). This compared with 2% in the group that received usual care. Screening rates in the mailed FOBT only group and in the mailed FOBT and outreach group were not significantly different (P = .28). CONCLUSIONS: Culturally appropriate clinic-based interventions may increase colorectal cancer screening among underserved Hispanics.

Access to water source, latrine facilities and other risk factors of active trachoma in Ankober, Ethiopia.

OBJECTIVE: This study aims to determine the prevalence and correlates of active trachoma in Ankober, Ethiopia. METHODS: A cross-sectional community-based study was conducted during July 2007. A total of 507 children (ages 1-9 years), from 232 households were included in the study. All children were examined for trachoma by ophthalmic nurses using the WHO simplified clinical grading system. Interviews and observations were used to assess risk factors. Logistic regression procedures were used to determine associations between potential risk factors and signs of active trachoma. RESULTS: Overall, the prevalence of active trachoma was found to be 53.9% (95%CI 49.6%-58.2%). Presence of fly-eye (fly contact with the eyelid margin during eye examination) (Odds Ratio (OR) = 4.03 95% CI 1.40-11.59), absence of facial cleanliness (OR = 7.59; 95%CI 4.60-12.52), an illiterate mother (OR = 5.88; 95%CI 2.10-15.95), lack of access to piped water (OR = 2.19; 95%CI 1.14-6.08), and lack of access to latrine facilities (OR = 4.36; 95%CI 1.49-12.74) were statistically significantly associated with increased risk of active trachoma. CONCLUSION: Active trachoma among children 1-9 years of age in Ankober is highly prevalent and significantly associated with a number of risk factors including access to water and latrine facilities. Trachoma prevention programs that include improved access to water and sanitation, active fly control, and hygiene education are recommended to lower the burden of trachoma in Ankober, Ethiopia.