Variation in Initiation, Engagement, and Retention on Medications for Opioid Use Disorder Based on Health Insurance Plan Design.

BACKGROUND: The association between cost-sharing and receipt of medication for opioid use disorder (MOUD) is unknown. METHODS: We constructed a cohort of 10,513 commercially insured individuals with a new diagnosis of opioid use disorder and information on insurance cost-sharing in a large national deidentified claims database. We examined 4 cost-sharing measures: (1) pharmacy deductible; (2) medical service deductible; (3) pharmacy medication copay; and (4) medical office copay. We measured MOUD (naltrexone, buprenorphine, or methadone) initiation (within 14 d of diagnosis), engagement (second receipt within 34 d of first), and 6-month retention (continuous receipt without 14-d gap). We used multivariable logistic regression to assess the association between cost-sharing and MOUD initiation, engagement, and retention. We calculated total out-of-pocket costs in the 30 days following MOUD initiation for each type of MOUD. RESULTS: Of 10,513 individuals with incident opioid use disorder, 1202 (11%) initiated MOUD, 742 (7%) engaged, and 253 (2%) were retained in MOUD at 6 months. A high ($1000+) medical deductible was associated with a lower odds of initiation compared with no deductible (odds ratio: 0.85, 95% confidence interval: 0.74-0.98). We found no significant associations between other cost-sharing measures for initiation, engagement, or retention. Median initial 30-day out-of-pocket costs ranged from $100 for methadone to $710 for extended-release naltrexone. CONCLUSIONS: Among insurance plan cost-sharing measures, only medical services deductible showed an association with decreased MOUD initiation. Policy and benefit design should consider ways to reduce cost barriers to initiation and retention in MOUD.

Hazardous Alcohol Use, Impulsivity, and HIV-Risk Behavior Among HIV-Positive Russian Patients With a History of Injection Drug Use.

BACKGROUND AND OBJECTIVES: Previous findings on the association between hazardous drinking and HIV-risk behavior have been equivocal, varying by population and individual difference factors. This study examined associations between hazardous drinking, impulsivity, and HIV-risk behaviors among HIV-positive Russian patients with a history of injection drug use (IDU), not on antiretroviral therapy. METHODS: Negative binomial regression analyses of data from a randomized controlled trial were performed (N = 241). Main independent variables were the Alcohol Use Disorders Identification Test and the Barratt Impulsiveness Scale. Outcomes were number of condomless sexual episodes (CSE; primary), number of sexual partners, and needle-sharing frequency (secondary). RESULTS: Hazardous drinking was positively associated with the frequency of CSE (adjusted incidence rate ratio [aIRR] = 2.16, 95% confidence interval [CI], 1.98-2.36). Moderate (aIRR = 0.51, 95% CI, 0.46-0.56) and high (aIRR = 0.66, 95% CI, 0.60-0.73) impulsivity were associated with fewer CSE compared with low impulsivity. Hazardous drinking (aIRR = 0.64, 95% CI, 0.52-0.79) and impulsivity (aIRR = 0.95, 95% CI, 0.94-0.96) were both associated with fewer sexual partners. Hazardous drinking and impulsivity were each associated with increased needle sharing. The association between hazardous drinking and number of needle-shares was strongest at higher impulsivity levels. CONCLUSION AND SCIENTIFIC SIGNIFICANCE: Hazardous drinking may be a risk factor for CSE among HIV-positive Russian patients and may influence needle sharing. Findings contribute to our understanding of the interactive associations between hazardous drinking and impulsivity with sexual risk behaviors and needle sharing among HIV-positive Russian patients with a history of IDU. (Am J Addict 2020;00:00-00).

Beyond Gender Identity Disorder Diagnoses Codes: An Examination of Additional Methods to Identify Transgender Individuals in Administrative Databases.

BACKGROUND: Large administrative databases often do not capture gender identity data, limiting researchers' ability to identify transgender people and complicating the study of this population. OBJECTIVE: The objective of this study was to develop methods for identifying transgender people in a large, national dataset for insured adults. RESEARCH DESIGN: This was a retrospective analysis of administrative claims data. After using gender identity disorder (GID) diagnoses codes, the current method for identifying transgender people in administrative data, we used the following 2 strategies to improve the accuracy of identifying transgender people that involved: (1) Endocrine Disorder Not Otherwise Specified (Endo NOS) codes and a transgender-related procedure code; or (2) Receipt of sex hormones not associated with the sex recorded in the patient's chart (sex-discordant hormone therapy) and an Endo NOS code or transgender-related procedure code. SUBJECTS: Seventy-four million adults 18 years and above enrolled at some point in commercial or Medicare Advantage plans from 2006 through 2017. RESULTS: We identified 27,227 unique transgender people overall; 18,785 (69%) were identified using GID codes alone. Using Endo NOS with a transgender-related procedure code, and sex-discordant hormone therapy with either Endo NOS or transgender-related procedure code, we added 4391 (16%) and 4051 (15%) transgender people, respectively. Of the 27,227 transgender people in our cohort, 8694 (32%) were transmasculine, 3959 (15%) were transfeminine, and 14,574 (54%) could not be classified. CONCLUSION: In the absence of gender identity data, additional data elements beyond GID codes improves the identification of transgender people in large, administrative claims databases.

Longitudinal Stigma Reduction in People Living with HIV Experiencing Homelessness or Unstable Housing Diagnosed With Mental Health or Substance Use Disorders: An Intervention Study.

Objectives. To assess changes in perceived external stigma among people living with HIV (PLWH) experiencing homelessness or unstable housing diagnosed with mental health or substance use disorders following an intervention including care coordination and navigation assistance, building trusting relationships, addressing unmet needs, and reducing barriers to seeking and engaging in care.Methods. This study was part of a national multisite intervention project delivered at 6 geographically diverse sites throughout the United States from September 2013 through February 2017. Participant surveys were conducted at baseline, 6 months, and 12 months. We assessed perceived external stigma, defined as people's beliefs about others' attitudes toward them, related to HIV, homelessness, mental health disorders, and substance use disorders with modified stigma scales.Results. A total of 548 individuals participated. At baseline, more participants reported experiencing any perceived external HIV stigma (81%) than any stigma related to homelessness and mental health or substance use disorders (38.9%). Over time, those reporting any HIV stigma decreased significantly from baseline (81%) to 61.4% and 57.8% at 6 and 12 months, respectively.Conclusions. PLWH experiencing homelessness or unstable housing with mental health or substance use disorders are impacted by multilayered stigma. Interventions to engage them in care may help reduce stigma.

Standardizing nurse training strategies to improve knowledge and self-efficacy with tracheostomy and laryngectomy care.

OBJECTIVE: Appropriate tracheostomy and laryngectomy care requires that nurses maintain specific knowledge and a particular skillset, to ensure safe, competent care. Deficiencies in this nursing care remain a persistent problem. The objective of this study was to evaluate the effect of a nurse training program on knowledge and self-efficacy with tracheostomy and laryngectomy care. STUDY DESIGN: Prospective, interventional survey design. SETTING: Academic, tertiary care hospital between September 2014 and April 2015. SUBJECTS AND METHODS: 1450 nurses at an academic tertiary care hospital were surveyed on tracheostomy and laryngectomy care at two time points: before and after the implementation and completion of the nurse training program. The nurse training program included a hands-on training session and online tutorial on appropriate tracheostomy and laryngectomy care. 732 nurses completed the hands-on training and were asked to complete the online tutorial. A total of 338 surveys were collected. Survey data were collected through an online survey development platform. Analyses were performed using SAS software. Chi-square tests and t-tests were utilized with a significance level of 0.05. RESULTS: 165 pre-training surveys and 173 post-training surveys were completed. Statistical analysis of the post-training data demonstrated statistically significantly higher knowledge and self-efficacy scores of nurses who completed the training than nurses who did not. CONCLUSIONS: Findings from this study reveal poor overall nursing knowledge and self-efficacy with this care and suggest that optimizing and standardizing nurse training is an effective strategy to improve nursing knowledge and self-efficacy with head and neck surgical airways.

Variation in Sedative and Analgesic Use During the COVID-19 Pandemic and Associated Outcomes.

BACKGROUND: Providing analgesia and sedation is an essential component of caring for many mechanically ventilated patients. The selection of analgesic and sedative medications during the COVID-19 pandemic, and the impact of these sedation practices on patient outcomes, remain incompletely characterized. RESEARCH QUESTION: What were the hospital patterns of analgesic and sedative use for patients with COVID-19 who received mechanical ventilation (MV), and what differences in clinical patient outcomes were observed across prevailing sedation practices? STUDY DESIGN AND METHODS: We conducted an observational cohort study of hospitalized adults who received MV for COVID-19 from February 2020 through April 2021 within the Society of Critical Care Medicine Discovery Viral Infection and Respiratory Illness Universal Study (VIRUS) COVID-19 Registry. To describe common sedation practices, we used hierarchical clustering to group hospitals based on the percentage of patients who received various analgesic and sedative medications. We then used multivariable regression models to evaluate the association between hospital analgesia and sedation cluster and duration of MV (with a placement of death [POD] approach to account for competing risks). RESULTS: We identified 1,313 adults across 35 hospitals admitted with COVID-19 who received MV. Two clusters of analgesia and sedation practices were identified. Cluster 1 hospitals generally administered opioids and propofol with occasional use of additional sedatives (eg, benzodiazepines, alpha-agonists, and ketamine); cluster 2 hospitals predominantly used opioids and benzodiazepines without other sedatives. As compared with patients in cluster 2, patients admitted to cluster 1 hospitals underwent a shorter adjusted median duration of MV with POD (ß-estimate, -5.9; 95% CI, -11.2 to -0.6; P = .03). INTERPRETATION: Patients who received MV for COVID-19 in hospitals that prioritized opioids and propofol for analgesia and sedation experienced shorter adjusted median duration of MV with POD as compared with patients who received MV in hospitals that primarily used opioids and benzodiazepines.

Impact of lifetime alcohol use on liver fibrosis in a population of HIV-infected patients with and without hepatitis C coinfection.

BACKGROUND: The effect of alcohol on liver disease in HIV infection has not been well characterized. METHODS: We performed a cross-sectional multivariable analysis of the association between lifetime alcohol use and liver fibrosis in a longitudinal cohort of HIV-infected patients with alcohol problems. Liver fibrosis was estimated with 2 noninvasive indices, "FIB-4," which includes platelets, liver enzymes, and age; and aspartate aminotransferase/platelet ratio index ("APRI"), which includes platelets and liver enzymes. FIB-4 <1.45 and APRI <0.5 defined the absence of liver fibrosis. FIB-4 >3.25 and APRI >1.5 defined advanced liver fibrosis. The main independent variable was lifetime alcohol consumption (<150 kg, 150 to 600 kg, >600 kg). RESULTS: Subjects (n = 308) were 73% men, mean age 43 years, 49% with hepatitis C virus (HCV) infection, 60% on antiretroviral therapy, 49% with an HIV RNA load <1,000 copies/ml, and 18.7% with a CD4 count <200 cells/mm(3) . Forty-five percent had lifetime alcohol consumption >600 kg, 32.7% 150 to 600 kg, and 22.3% <150 kg; 33% had current heavy alcohol use, and 69% had >9 years of heavy episodic drinking. Sixty-one percent had absence of liver fibrosis and 10% had advanced liver fibrosis based on FIB-4. In logistic regression analyses, controlling for age, gender, HCV infection, and CD4 count, no association was detected between lifetime alcohol consumption and the absence of liver fibrosis (FIB-4 <1.45) (adjusted odds ratio [AOR] = 1.12 [95% CI: 0.25 to 2.52] for 150 to 600 kg vs. <150 kg; AOR = 1.11 [95% CI: 0.52 to 2.36] for >600 kg vs. <150 kg; global p = 0.95). Additionally, no association was detected between lifetime alcohol use and advanced liver fibrosis (FIB-4 >3.25). Results were similar using APRI, and among those with and without HCV infection. CONCLUSIONS: In this cohort of HIV-infected patients with alcohol problems, we found no significant association between lifetime alcohol consumption and the absence of liver fibrosis or the presence of advanced liver fibrosis, suggesting that alcohol may be less important than other known factors that promote liver fibrosis in this population.

Human immunodeficiency virus, hepatitis C, and inflammatory biomarkers in individuals with alcohol problems: a cross-sectional study.

BACKGROUND: Assessing whether hepatitis C (HCV) co-infection with human immunodeficiency virus (HIV) is associated with increased inflammation is complex. The liver, integral to inflammatory biomarker synthesis, is compromised by HCV and alcohol abuse. Using single liver-synthesized biomarkers (e.g. C-reactive protein) to represent inflammation may not be appropriate in HIV/HCV co-infection. We hypothesized that 1) detectable HIV/HCV RNA was independently associated with increased inflammation; 2) a composite inflammation measure describes inflammation differently from single inflammatory biomarkers. METHODS: We compared inflammation by HIV/HCV group in a cohort of 361 HIV infected participants from the HIV-Longitudinal Interrelationships of Viruses and Ethanol study. Inflammatory biomarkers >75th percentile were considered elevated. Associations between HIV/HCV group and elevated biomarkers were analyzed as a composite measure (inflammatory burden) or individually. We defined inflammatory burden as number of concurrently elevated biomarkers. Biomarkers included interleukin-6 (IL-6), C-reactive protein (CRP), cystatin C, serum amyloid-A (SAA), tumor necrosis factor-alpha (TNF-α), interleukin-10 (IL-10). Covariates: alcohol, liver fibrosis, comorbidities, CD4 count, antiretroviral therapy, substance use. RESULTS: Detectable HIV and HCV RNA (OR = 2.49; 95% CI = 1.05-5.89) and detectable HCV RNA alone (2.95; 1.08-8.01) were independently associated with increased odds of having a greater inflammatory burden compared to undetectable viremia. Elevated IL-10 (7.79; 1.90-31.97) and TNF-α (7.70; 1.42-41.83) were independently associated with detectable HIV and HCV RNA. Elevated IL-10 was also associated with detectable HCV RNA alone (5.51; 1.17, 25.84). CONCLUSIONS: Detectable HIV and HCV replication versus undetectable replication was associated with inflammatory burden and certain inflammatory biomarkers independently of alcohol consumption, liver fibrosis and other comorbidities.

Trends in Feminizing Hormone Therapy for Transgender Patients, 2006-2017.

Combination therapy with estrogen and spironolactone may help some transgender women achieve desired results. We used two databases, OptumLabs® Data Warehouse (OLDW) and Veterans Health Administration (VHA), to examine trends in feminizing therapy. We included 3368 transgender patients from OLDW and 3527 from VHA, all of whom received estrogen, spironolactone, or both between 2006 and 2017. In OLDW, the proportion receiving combination therapy increased from 47% to 75% during this period. Similarly, in VHA, the proportion increased from 39% to 69% during this period. We conclude that the use of combination hormone therapy has become much more common over the past decade.

Self-reported adherence with the use of a device in a clinical trial as validated by electronic monitors: the VIBES study.

BACKGROUND: Adherences to treatments that require a behavioral action often rely on self-reported recall, yet it is vital to determine whether real time self reporting of adherence using a simple logbook accurately captures adherence. The purpose of this study was to determine whether real time self-reported adherence is an accurate measurement of device usage during a clinical trial by comparing it to electronic recording. METHODS: Using data collected from older adult men and women (N=135, mean age 82.3 yrs; range 66 to 98 yrs) participating in a clinical trial evaluating a vibrating platform for the treatment of osteoporosis, daily adherence to platform treatment was monitored using both self-reported written logs and electronically recorded radio-frequency identification card usage, enabling a direct comparison of the two methods over one year. Agreement between methods was also evaluated after stratification by age, gender, time in study, and cognition status. RESULTS: The two methods were in high agreement (overall intraclass correlation coefficient = 0.96). The agreement between the two methods did not differ between age groups, sex, time in study and cognitive function. CONCLUSIONS: Using a log book to report adherence to a daily intervention requiring a behavioral action in older adults is an accurate and simple approach to use in clinical trials, as evidenced by the high degree of concordance with an electronic monitor.

Potential barriers to filling buprenorphine and naltrexone prescriptions among a retrospective cohort of individuals with opioid use disorder.

INTRODUCTION: Medications for opioid use disorder (MOUD) are highly effective, but barriers along the cascade of care for opioid use disorder (OUD) from diagnosis to treatment limit their reach. For individuals desiring MOUD, the final step in the cascade is filling a written prescription, and fill rates have not been described. METHODS: We used data from a large de-identified database linking individuals' electronic medical records (EMR) and administrative claims data and employed a previously developed algorithm to identify individuals with a new diagnosis of OUD. We included individuals with a prescription for buprenorphine or naltrexone recorded in the EMR. The outcome was a prescription fill within 30 days as reported in claims data. We compared demographic and clinical characteristics between those who did and did not fill the prescription and used a Kaplan-Meier curve to assess whether fill rates differed based on patient copay. RESULTS: We identified 264 individuals with a new diagnosis of OUD who had a prescription written for buprenorphine or oral naltrexone. Of these, 70% (184) filled the prescription within 30 days, and more than half (57%) filled the prescription on the day it was written. Individuals with prescription copay at or below the mean had a 75% fill rate at 30 days compared with 63% for those with copay above the mean (p < 0.05) and this difference was consistent across fill times (log rank p-value <0.05). CONCLUSIONS: It is alarming that nearly 1 in 3 MOUD prescriptions go unfilled. More research is needed to understand and reduce barriers to this final step of the OUD cascade of care.

Considering Quality Measures for the Care of Transgender Patients: Preliminary Findings from a Technical Expert Panel.

Purpose: Transgender (TG) individuals are a historically understudied and underserved patient population. Although clinical guidelines for the care of TG patients exist, quality measures (QMs) specific to this population are lacking. The goal of this study was to obtain expert input on aspects of care for which quality measurement may be appropriate and describe feedback on candidate QMs. Methods: We convened a virtual technical expert panel in September 2020 with six experts in TG medical care. Experts participated in a guided discussion and provided numeric ratings on dimensions of measure suitability (importance, validity/reliability, feasibility, and ease of understanding) for eight candidate QMs spanning multiple care domains (e.g., laboratory testing/monitoring, cancer screening, and sexually transmitted infection screening). Results: Panelists acknowledged high importance and potential to improve care for some candidate QMs, particularly those related to laboratory testing before initiating and during hormone therapy. Numeric ratings of QMs varied but tended to be higher for testing-focused QMs. Experts raised concerns about overly prescriptive language for some QMs and emphasized the importance of considering more flexible specifications to accommodate diverse care scenarios-including care provided to nonbinary individuals-and align with the individualized nature of gender-affirming care. Conclusion: These preliminary findings support a potential role for QMs in improving quality of care for TG patients. Measures related to laboratory testing/monitoring for patients who receive or plan to initiate hormone therapy may be feasible and promising to explore in the future. Additional larger-scale efforts are needed to develop and test QMs for the care of TG individuals.

Prevalence and Co-occurrence of Alcohol, Nicotine, and Other Substance Use Disorder Diagnoses Among US Transgender and Cisgender Adults.

Importance: Substance use disorders are a major source of morbidity and mortality in the United States. National data comparing the prevalence of substance use disorder diagnoses (SUDDs) among transgender and cisgender individuals are lacking in the United States. Objectives: To investigate the prevalence of SUDDs among transgender and cisgender adults and to identify within-group and between-group differences by age, gender, and geographic location. Design, Setting, and Participants: This cross-sectional study used the OptumLabs Data Warehouse to analyze deidentified claims from approximately 74 million adults aged 18 years or older enrolled in commercial or Medicare Advantage insurance plans in 2017. A total of 15 637 transgender adults were identified based on a previously developed algorithm using a combination of International Classification of Diseases, Tenth Revision (ICD-10) transgender-related diagnosis and procedure codes and sex-discordant hormone prescriptions. A cohort of 46 911 cisgender adults was matched to the transgender cohort in a 3:1 ratio based on age and geographic location. Main Outcomes and Measures: SUDDs, based on ICD-10 codes, were assessed overall and compared between transgender and cisgender cohorts and by geographic region (ie, Northeast, Midwest, South, and West); age groups (eg, 18-25, 26-30, 31-35 years), and gender (ie, transfeminine [TF; assigned male sex at birth, identify along feminine gender spectrum], transmasculine [TM; assigned female sex at birth, identify along masculine gender spectrum], male, and female). Results: In this study of 15 637 transgender adults (4955 [31.7%] TM) and 46 911 cisgender adults (23 247 [50.4%] men), most (8627 transgender adults [55.2%]; 51 762 cisgender adults [55.2%]) were aged between 18 and 40 years, and 6482 transgender adults (41.5%) and 19 446 cisgender adults (41.5%) lived in the South. Comparing transgender to cisgender groups, significant differences were found in the prevalence of a nicotine (2594 [16.6%] vs 2551 [5.4%]; P < .001), alcohol (401 [2.6%] vs 438 [0.9%]; P < .001), and drug (678 [4.3%] vs 549 [1.2%]; P < .001) SUDDs. Among transgender adults, cannabis was the most prevalent drug SUDD (321 [2.1%]), followed by opioid SUDD (205 [1.3%]) and cocaine SUDD (81 [0.5%]), whereas among cisgender adults, cannabis and opioid SUDDs were equally prevalent (cannabis, 186 [0.4%]; opioid, 207 [0.4%]), followed by cocaine SUDD (59 [0.1%]). Conclusions and Relevance: In this study, the prevalence of SUDDs was significantly elevated among transgender adults relative to their cisgender peers. These findings underscore the need for culturally tailored clinical interventions to treat substance use disorder in transgender populations.

Examination of Food Insecurity, Socio-Demographic, Psychosocial, and Physical Factors among Residents in Public Housing.

Objectives: Understanding associations between psychosocial and physical factors among those who experience food insecurity could help design effective food insecurity programs for improved cardiovascular health among low-income populations. We examined differences in psychosocial and physical factors between those who were food secure compared with food insecure among public housing residents. Methods: Data were from the baseline survey of a randomized controlled trial of a weight management intervention in Boston, Massachusetts from 2016-2017. Food insecurity and psychosocial and physical factors, including perceived stress, personal problems, social support, and physical symptoms, were measured via interviewer-administered screeners. Results: Mean age of the sample (N=102) was 46.5 years (SD=11.9). The majority were Hispanic (67%), female (88%), with ≤high school degree (62%). Nearly half were food insecure (48%). For psychosocial variables, those who were food insecure had higher ratings of perceived stress (adjusted mean difference 3.39, 95% CI:2.00,4.79), a higher number of personal problems (adjusted mean difference 1.85, 95% CI: 1.19, 2.51), and lower social support (adjusted mean difference -0.70, 95% CI:-1.30,-0.11) compared with those who were food secure. For physical variables, those who were food insecure had higher odds of reporting negative physical symptoms (aOR 4.92, 95% CI:1.84,13.16). Conclusion: Among this sample of public housing residents, food insecurity was associated with higher stress, more personal problems, higher experiences of physical symptoms, and lower social support.

Community health worker-delivered weight management intervention among public housing residents: A feasibility study.

Community health worker-led interventions may be an optimal approach to promote behavior change among populations with low incomes due to the community health workers' unique insights into participants' social and environmental contexts and potential ability to deliver interventions widely. The objective was to determine the feasibility (implementation, acceptability, preliminary efficacy) of a weight management intervention for adults living in public housing developments. In 2016-2018, in Boston Massachusetts, we conducted a 3-month, two-group randomized trial comparing participants who received a tailored feedback report (control group) to participants who received the same report plus behavioral counseling. Community health workers provided up to 12 motivational interviewing-based counseling sessions in English or Spanish for diet and physical activity behaviors using a website designed to guide standardized content delivery. 102 participants enrolled; 8 (7.8%) were lost at 3-month follow up. Mean age was 46.5 (SD = 11.9) years; the majority were women (88%), Hispanic (67%), with ≤ high school degree (62%). For implementation, among intervention group participants (n = 50), 5 completed 0 sessions and 45 completed a mean of 4.6 (SD = 3.1) sessions. For acceptability, most indicated they would be very likely (79%) to participate again. For preliminary efficacy, adjusted linear regression models showed mean changes in weight (-0.94 kg, p = 0.31), moderate-to-vigorous physical activity (+11.7 min/day, p = 0.14), and fruit/vegetable intake (+2.30 servings/day, p < 0.0001) in the intervention vs. control group. Findings indicate a low-income public housing population was reached through a community health worker-led intervention with sufficient implementation and acceptability and promising beneficial changes in weight, nutrition, and physical activity outcomes.

Comparative Effectiveness of Heart Rate Control Medications for the Treatment of Sepsis-Associated Atrial Fibrillation.

BACKGROUND: Atrial fibrillation (AF) with rapid ventricular response frequently complicates the management of critically ill patients with sepsis and may necessitate the initiation of medication to avoid hemodynamic compromise. However, the optimal medication to achieve rate control for AF with rapid ventricular response in sepsis is unclear. RESEARCH QUESTION: What is the comparative effectiveness of frequently used AF medications (ß-blockers, calcium channel blockers, amiodarone, and digoxin) on heart rate (HR) reduction among critically ill patients with sepsis and AF with rapid ventricular response? STUDY DESIGN AND METHODS: We conducted a multicenter retrospective cohort study among patients with sepsis and AF with rapid ventricular response (HR > 110 beats/min). We compared the rate control effectiveness of ß-blockers to calcium channel blockers, amiodarone, and digoxin using multivariate-adjusted, time-varying exposures in competing risk models (for death and addition of another AF medication), adjusting for fixed and time-varying confounders. RESULTS: Among 666 included patients, 50.6% initially received amiodarone, 10.1% received a ß-blocker, 33.8% received a calcium channel blocker, and 5.6% received digoxin. The adjusted hazard ratio for HR of < 110 beats/min by 1 h was 0.50 (95% CI, 0.34-0.74) for amiodarone vs ß-blocker, 0.37 (95% CI, 0.18-0.77) for digoxin vs ß-blocker, and 0.75 (95% CI, 0.51-1.11) for calcium channel blocker vs ß-blocker. By 6 h, the adjusted hazard ratio for HR < 110 beats/min was 0.67 (95% CI, 0.47-0.97) for amiodarone vs ß-blocker, 0.60 (95% CI, 0.36-1.004) for digoxin vs ß-blocker, and 1.03 (95% CI, 0.71-1.49) for calcium channel blocker vs ß-blocker. INTERPRETATION: In a large cohort of patients with sepsis and AF with rapid ventricular response, a ß-blocker treatment strategy was associated with improved HR control at 1 h, but generally similar HR control at 6 h compared with amiodarone, calcium channel blocker, or digoxin.

Pathways to housing stability and viral suppression for people living with HIV/AIDS: Findings from the Building a Medical Home for Multiply Diagnosed HIV-positive Homeless Populations initiative.

BACKGROUND: People with HIV with co-occurring substance use and mental health diagnoses who are unstably housed have poorer outcomes for retention in care and viral suppression. Navigation models are a potential strategy to help this vulnerable population obtain the necessary medical and non-medical services across multiple service systems. The Health Resources and Services Administration's Special Projects of National Significance: "Building a Medical Home for Multiply-Diagnosed HIV-positive Homeless Populations initiative 2012-2017 found that navigation models may be an effective intervention to support people with HIV with unstable housing improve HIV health outcomes. However, there is limited information about the mechanisms by which this intervention works. In this article, we explore the participant and program factors for achieving stable housing at 6 months and how these factors influence HIV health outcomes. METHODS AND FINDINGS: This was a prospective study of 471 unstably housed people with HIV enrolled in a navigation intervention across nine sites in the United Stated from 2013-2017. All sites provided HIV primary medical care. Eight sites were located in urban areas and one site served a predominantly rural population. Two sites were federally qualified health centers, three were city or county health departments, one site was a comprehensive HIV/AIDS service organization, and three sites were outpatient or mobile clinics affiliated with a university -based or hospital system. Data were collected via interview and medical chart review at baseline, post 6 and 12 months. Type and dose of navigation activities were collected via a standardized encounter form. We used a path analysis model with housing stability at 6 months as the mediator to examine the direct and indirect effects of participant's socio-demographics and risk factors and navigation on viral suppression and retention in care at 12 months. Housing stability at 6 months was associated with male gender, younger age, viral suppression at baseline, having a lower risk for opiate use, recent homelessness, lower risk of food insecurity, and a longer length of time living with HIV. Participants who increased self-efficacy with obtaining help by 6 months had significantly higher odds of achieving housing stability. Stable housing, fewer unmet needs, moderate to high risk for opiate use, and viral suppression at baseline had a direct effect on viral suppression at 12 months. The intensity of navigation contact had no direct effect on housing stability and a mixed direct effect on viral suppression. Recent diagnosis with HIV, women, greater social support, increased self-efficacy and higher intensity of navigation contact had a direct effect on improved retention in HIV primary care at 12 months. CONCLUSIONS: In this sample of people with HIV who are experiencing homelessness, housing stability had a significant direct path to viral suppression. Navigation activities did not have a direct effect on the path to housing stability but were directly related to retention in care. These results identify key populations and factors to target resources and policies for addressing the health and social unmet needs of people with HIV to achieve housing stability and HIV health outcomes.

A strengths-based case management intervention to link HIV-positive people who inject drugs in Russia to HIV care.

OBJECTIVE: To determine whether the Linking Infectious and Narcology Care strengths-based case management intervention was more effective than usual care for linking people who inject drugs (PWID) to HIV care and improving HIV outcomes. DESIGN: Two-armed randomized controlled trial. SETTING: Participants recruited from a narcology hospital in St. Petersburg, Russia. PARTICIPANTS: A total of 349 HIV-positive PWID not on antiretroviral therapy (ART). INTERVENTION: Strengths-based case management over 6 months. MAIN OUTCOME MEASURES: Primary outcomes were linkage to HIV care and improved CD4 cell count. We performed adjusted logistic and linear regression analyses controlling for past HIV care using the intention-to-treat approach. RESULTS: Participants (N = 349) had the following baseline characteristics: 73% male, 12% any past ART use, and median values of 34.0 years of age and CD4 cell count 311 cells/µl. Within 6 months of enrollment 51% of the intervention group and 31% of controls linked to HIV care (adjusted odds ratio 2.34; 95% confidence interval: 1.49-3.67; P < 0.001). Mean CD4 cell count at 12 months was 343 and 354 cells/µl in the intervention and control groups, respectively (adjusted ratio of means 1.14; 95% confidence interval: 0.91, 1.42, P = 0.25). CONCLUSION: The Linking Infectious and Narcology Care strengths-based case management intervention was more effective than usual care in linking Russian PWID to HIV care, but did not improve CD4 cell count, likely due to low overall ART initiation. Although case management can improve linkage to HIV care, specific approaches to initiate and adhere to ART are needed to improve clinical outcomes (e.g., increased CD4 cell count) in this population.

Fatal and non-fatal overdose after narcology hospital discharge among Russians living with HIV/AIDS who inject drugs.

OBJECTIVES: Among Russians living with HIV/AIDS who inject drugs, we examined the incidence of fatal and non-fatal overdoses following discharge from a narcology hospital and the associations with more advanced HIV infection. DESIGN: Prospective cohort study of data collected at baseline, 3 and 6 months from HIV-infected patients with a history of injection drug use who were not treated with anti-retroviral therapy. Participants were recruited between 2012-2014 from a narcology (addiction) hospital in St. Petersburg, Russia. METHODS: Fatal overdose was determined based on contact reports to study staff in the year after discharge. Non-fatal overdose was self-reported at the 3- and 6-month assessments. The main independent variable for HIV severity was CD4 cell count at the baseline interview (<200cells/mm3≥200cells/mm3). Secondary analyses assessed time since HIV diagnosis and treated with anti-retroviral treatment (ART) prior to enrolment as independent variables. We fit Cox proportional hazards models to assess whether HIV severity is associated with either fatal or non-fatal overdose. RESULTS: Among 349 narcology patients, 18 participants died from overdose within one year after discharge (8.7%, 95% CI 3.4-14.2 by Kaplan-Meier); an estimated 51% [95% CI 34-68%] reported at least one non-fatal overdose within 6 months of discharge. HIV severity, time since HIV diagnosis and ever ART were not significantly associated with either fatal or non-fatal overdose events. CONCLUSION: Fatal and non-fatal overdose are common among Russians living with HIV/AIDS who inject drugs after narcology hospital discharge. Overdose prevention interventions are urgently warranted among Russian narcology patients with HIV infection.