Injections and infections: understanding syringe service program utilization in a rural state.

BACKGROUND: Increasing rates of injection drug use (IDU) associated-infections suggest significant syringe service program (SSP) underutilization. Our study objective was to assess practices of safe injection techniques and to determine predictors of SSP utilization in a rural state. PATIENTS AND METHODS: This was a fifteen-month cross-sectional study of participants hospitalized with IDU-associated infections in Maine. Data were collected through Audio Computer-Assisted Self-Interview survey and medical record review. Descriptive analyses were performed to characterize demographics, health characteristics, and injection practices. The primary outcome was SSP utilization, and the main independent variable was self-reported distance to SSP. Logistic regression analyses were performed to identify factors associated SSP utilization, controlling for gender, homelessness, history of overdose, having a primary care physician and distance to SSP. RESULTS: Of the 101 study participants, 65 participants (64%) reported past 3 month SSP utilization, though only 33% used SSPs frequently. Many participants (57%) lived more than 10 miles from an SSP. Participants who lived less than 10 miles of an SSP were more likely to use an SSP (adjusted odds ratio 5.4; 95% CI 1.9-15.7). CONCLUSIONS: Our study highlights unsafe injection practices and lack of frequent SSP utilization among people admitted with IDU-associated infections in a rural state. Especially given increasing stimulant use, these results also highlight the need for SSP access. Particularly in rural areas where patients may live more than 10 miles from an SSP, expansion of harm reduction services, including mobile units, should be a priority.

Redesigning the Clinical Learning Environment to Improve Interprofessional Care and Education: Multi-Method Program Evaluation of the iPACE Pilot Unit.

BACKGROUND: In 2016, Maine Medical Center received an Accreditation Council for Graduate Medical Education Pursuing Excellence in Innovation grant to redesign the clinical learning environment to promote interprofessional care and education. The Interprofessional Partnership to Advance Care and Education (iPACE) model was developed and piloted on an adult inpatient medicine unit as an attempt achieve these aims. OBJECTIVE: We describe the iPACE model and associated outcomes. METHODS: Surveys and focus groups were employed as part of a multimethod pragmatic observational strategy. Team surveys included relational coordination (RC): a validated proprietary measure of interpersonal communication and relationships within teams. Pre-iPACE respondents were a representative historical sample from comparable inpatient medical units surveyed from March to April 2017. iPACE respondents were model participants surveyed March to August 2018 to allow for adequate sample size. RESULTS: Surveys were administered to pre-iPACE (N = 113, response rate 74%) and iPACE (N = 32, 54%) teams. Summary RC scores were significantly higher for iPACE respondents (iPACE 4.26 [SD 0.37] vs 3.72 [SD 0.44], P < .0001), and these respondents were also more likely to report a professionally rewarding experience (iPACE 4.4 [SD 0.6] vs 3.5 [SD 1.0], P < .0001). Learners felt the model was successful in teaching interprofessional best practices but were concerned it may hinder physician role development. Patient experience was positive. CONCLUSIONS: This pilot may have a positive effect on team functioning and team member professional experience and patient experience. Learner acceptance may be improved by increasing autonomy and preserving traditional learning venues.

Comparison of intraoperative tranexamic acid and epsilon-aminocaproic acid in cardiopulmonary bypass patients.

Objective: To compare tranexamic acid (TXA) and epsilon-aminocaproic acid (EACA) in patients undergoing cardiac surgery with cardiopulmonary bypass. Methods: Over a consecutive 2-year period, 824 adult cardiac surgery patients who received TXA during an EACA shortage were compared with 778 patients who received EACA postshortage. Patient characteristics and process and outcome variables were collected through chart review and database queries. This retrospective analysis used inverse probability of treatment weighting to control for confounding by indication, and propensity scores were calculated using a logistic regression model. Results: In adjusted models, overall transfusion rates for the TXA cohort (odds ratio [OR], 0.94; 95% confidence interval [95% CI], 0.81-1.10) and administration of platelets (OR, 1.04; 95% CI, 0.85-1.27), red blood cells (OR, 0.93; 95% CI, 0.80-1.09), fresh frozen plasma (OR, 1.00; 95% CI, 0.79-1.25), and cryoprecipitate (OR, 1.08; 95% CI, 0.71-1.64) were equivalent to the EACA cohort. In addition, there was no statistical difference with respect to stroke, seizure, mortality, reoperation for bleeding, chest tube drainage, and acute kidney injury. Patients who received TXA had shorter ventilator times (difference in medians -1.33 hours [95% CI, -1.86 to -0.80]) and lower postsurgical charges (difference of medians -$2913 [95% CI, -5147 to -679]). Conclusions: Substituting TXA for EACA during cardiac surgery with cardiopulmonary bypass did not change transfusion rate or amount, nor was there a significant difference in chest tube drainage. Patients who received TXA had a statistically significant but not clinically significant lower postoperative ventilator times and charges without an increase in mortality, stroke, reoperation for bleeding, acute kidney injury, or seizures.

Association of patient navigation with care coordination in an Lynch syndrome screening program.

Lynch syndrome (LS) identification leads to improved health outcomes. Universal tumor screening (UTS) facilitates LS identification among colorectal cancer (CRC) and uterine cancer (UC) cases; institutional management affects screening program implementation and outcomes. There has been limited study of institutional UTS program care coordination needs, including patient navigation of genetic counseling referrals. We examined the influence of patient navigators on access to cancer genetic services among LS UTS screen-positive cases within a single institution. Electronic health record review of screen-positive CRC and UC cases for a 12-month period assessed the relationship between patient navigation and follow-through to genetic services. Among 451 newly diagnosed CRC (n = 175) and UC (n = 276) cases, 96 (21%; 28 CRC/68 UC cases) had abnormal UTS results. Among these, 66 (69%) showed MLH1 promoter hypermethylation (i.e., screen-negative). Of 30 screen-positive cases, 16 (53%) received navigation services. Among these, 14/16 (88%) and 13/14 (81%) underwent genetic counseling and testing, respectively; 7/13 (54%) had pathogenic or likely pathogenic variants detected. Among non-navigated screen-positive patients, 2/14 (14%) were excluded due to incomplete UTS results. Five of the remaining 12 cases (42%) sought genetic counseling, 4/12 (33%) underwent genetic testing; 1/4 (25%) tested positive for a pathogenic variant. The difference in navigated (88%) versus non-navigated cases (42%) undergoing genetic counseling was statistically significant (p = .02). Patient navigation was associated with follow-through to genetic counseling and testing services among LS screen-positive cases. This model deserves additional prospective investigation to confirm these findings and to assess their generalizability.

Examination of the Patient-Focused Impact of Cancer Telegenetics Among a Rural Population: Comparison with Traditional In-Person Services.

BACKGROUND: Telecommunication models promise to improve access to cancer genetic counseling. Little is known about their impact among the geographically underserved. This work examined knowledge and emotional outcomes and attitudes/beliefs regarding cancer telegenetic services (via live-interactive videoconferencing) in Maine. MATERIALS AND METHODS: Cancer telegenetic patients seen at two remote sites and control (in-person) patients responded to pre-/postsurveys assessing care impact on hereditary breast and ovarian cancer (HBOC) knowledge and emotional health, ease of access to services, and telegenetics satisfaction/acceptability. RESULTS: 158/174 (90%) participants returned pre- and immediate postcounseling surveys (90 remote and 68 in-person). Fewer returned 1-month postsurveys. Remote patients were older with lower education levels, more likely to live in rural counties and to have cancer histories. The two groups were matched relative to gender, race, and health insurance status. HBOC knowledge improved equally in both groups pre- versus immediately postcounseling and was maintained at 1 month in both groups. Decreased anxiety was evident postcounseling with no significant difference between groups. Depression improved significantly in remote patients immediately postcounseling; 1-month depression measures were lower in both groups. The availability of telegenetics eased transportation needs/work absences, and patients reported satisfaction with telecommunication quality. Despite overall acceptance of telegenetics, 32% of remote patients noted preference for in-person care. CONCLUSIONS: There were few differences in HBOC knowledge and emotional outcomes comparing traditional in-person cancer genetic services with telegenetics, and satisfaction with/acceptance of this model was high. These data relate to scalability of cancer telegenetics in rural regions regionally and nationally.

Development of clinical models for predicting erectile function after localized prostate cancer treatment.

OBJECTIVES: To develop clinical prediction models estimating the probability of maintaining erections adequate for intercourse 2 years after prostate cancer treatment, based on pretreatment characteristics. METHODS: Study participants consisted of prostate cancer patients with localized disease and functional erections before undergoing surgery (n = 536) or radiation therapy (n = 240) at a single USA institution. Baseline patient- and treatment-related data were collected from a clinical database and through chart review. Erectile function at 2 years post-treatment was prospectively assessed through a self-administered single-item measure. Multivariate logistic regression using backward selection was used to derive clinical prediction models to predict erectile function at 2 years for surgery and radiation therapy patients; the models were internally validated using bootstrapping methods. RESULTS: The final prediction model for surgery patients included the predictor variables of age, body mass index, smoking, diabetes, hypertension and nerve-sparing procedures, whereas the model for radiation therapy patients included hypertension, risk category and radiation technique. The new models showed acceptable calibration and discrimination: c-statistic = 0.71 (95% confidence interval 0.68-0.76) for surgery and 0.66 (95% confidence interval 0.61-0.74) for radiation therapy models. CONCLUSIONS: New clinical prediction models based on patient and treatment characteristics show promising accuracy in predicting erectile function at 2 years in patients treated with surgery and radiation for localized prostate cancer. More work is required to confirm and validate these models in different patient populations.