Fifteen Years After Katrina: Paving the Way for Health Care Transformation.

Following the devastation of the Greater New Orleans, Louisiana, region by Hurricane Katrina, 25 nonprofit health care organizations in partnership with public and private stakeholders worked to build a community-based primary care and behavioral health network. The work was made possible in large part by a $100 million federal award, the Primary Care Access Stabilization Grant, which paved the way for innovative and sustained public health and health care transformation across the Greater New Orleans area and the state of Louisiana.

A Randomized Cohort Controlled Trial to Compare Intern Sign-Out Training Interventions.

BACKGROUND: Although previous studies have investigated the efficacy of specific sign-out protocols (such as the illness severity, patient summary, action list, situation awareness and contingency planning, and synthesis by reviewer [I-PASS] bundle), the implementation of a bundle can be time consuming and costly. We compared 4 sign-out training pedagogies on sign-out quality. OBJECTIVE: To evaluate training interventions that best enhance multidimensional sign-out quality measured by information exchange, task accountability, and personal responsibility. INTERVENTION: Four general internal medicine firms were randomly assigned into 1 of the following 4 training interventions: didactics (control), I-PASS, policy mandate on task accountability, and Plan-Do-Study-Act (PDSA). SETTING: First-year interns at a large, Mid-Atlantic internal medicine residency program. MEASUREMENTS: Eight trained observers examined 10 days each in the pre- and postintervention periods for each firm using a standardized sign-out checklist. RESULTS: Pre- and postintervention differences showed significant improvements in the transfer of patient information, task accountability, and personal responsibility for the I-PASS, policy mandate, and PDSA groups, respectively, in line with their respective training foci. Compared to the control, I-PASS reported the best improvements in sign-out quality, although there was room to improve in task accountability and responsibility. CONCLUSIONS: Different training emphases improved different dimensions of sign-out quality. A combination of training pedagogies is likely to yield optimal results.

Durable Suppression of HIV-1 after Virologic Monitoring-Based Antiretroviral Adherence Counseling in Rakai, Uganda.

OBJECTIVES: HIV viral load is recommended for monitoring antiretroviral treatment and identifying treatment failure. We assessed the durability of viral suppression after viral load-triggered adherence counseling among patients with HIV viremia 6 months after ART initiation. DESIGN: Observational cohort enrolled in an antiretroviral treatment program in rural Uganda. METHODS: Participants who underwent routine viral load determination every 24 weeks and had at least 48 weeks of follow-up were included in this analysis. Patients with viral loads >400 copies/ml at 24 weeks of treatment were given additional adherence counseling, and all patients were followed to assess the duration of viral suppression and development of virologic failure. RESULTS: 1,841 participants initiating antiretroviral therapy were enrolled in the Rakai Health Sciences Program between June 2005 and June 2011 and were followed with viral load monitoring every 24 weeks. 148 (8%) of patients did not achieve viral suppression at 24 weeks and were given additional adherence counseling. 85 (60%) of these patients had undetectable viral loads at 48 weeks, with a median duration of viral suppression of 240 weeks (IQR 193-288 weeks). Failure to achieve an undetectable viral load at 48 weeks was associated with age <30 years and 24 week viral load >2,000 copies/ml in multivariate logistic regression analysis. CONCLUSIONS: The majority of patients with persistent viremia who were provided adherence counseling achieved robust viral suppression for a median 4.6 years. Access to virologic monitoring and adherence counseling is a priority in resource-limited settings.

Treatment default amongst patients with tuberculosis in urban Morocco: predicting and explaining default and post-default sputum smear and drug susceptibility results.

SETTING: Public tuberculosis (TB) clinics in urban Morocco. OBJECTIVE: Explore risk factors for TB treatment default and develop a prediction tool. Assess consequences of default, specifically risk for transmission or development of drug resistance. DESIGN: Case-control study comparing patients who defaulted from TB treatment and patients who completed it using quantitative methods and open-ended questions. Results were interpreted in light of health professionals' perspectives from a parallel study. A predictive model and simple tool to identify patients at high risk of default were developed. Sputum from cases with pulmonary TB was collected for smear and drug susceptibility testing. RESULTS: 91 cases and 186 controls enrolled. Independent risk factors for default included current smoking, retreatment, work interference with adherence, daily directly observed therapy, side effects, quick symptom resolution, and not knowing one's treatment duration. Age >50 years, never smoking, and having friends who knew one's diagnosis were protective. A simple scoring tool incorporating these factors was 82.4% sensitive and 87.6% specific for predicting default in this population. Clinicians and patients described additional contributors to default and suggested locally-relevant intervention targets. Among 89 cases with pulmonary TB, 71% had sputum that was smear positive for TB. Drug resistance was rare. CONCLUSION: The causes of default from TB treatment were explored through synthesis of qualitative and quantitative data from patients and health professionals. A scoring tool with high sensitivity and specificity to predict default was developed. Prospective evaluation of this tool coupled with targeted interventions based on our findings is warranted. Of note, the risk of TB transmission from patients who default treatment to others is likely to be high. The commonly-feared risk of drug resistance, though, may be low; a larger study is required to confirm these findings.