Evaluation of the Implementation of the FLOW Program for Increasing Access to Mental Health Care.

The FLOW program was designed to facilitate appropriate and safe transitions of patients from specialty mental health (SMH) to primary care (PC) as a method of improving access and reducing appointment burden on veterans who have improved or remitted. In this study, the team evaluated the implementation of FLOW across nine Veterans Affairs (VA) sites using a mixed-methods evaluation in a cluster-randomized stepped wedge trial design. Outcome assessments used data from VA databases, dashboards, and semi-structured interviews and were guided by the Reach, Adoption, Effectiveness, Implementation, and Maintenance (RE-AIM) framework. Across the sites, mean level reach was 1.36% of all specialty mental health patients transitioned to primary care (standard deviation [SD] = 1.05). Mean provider adoption was 10.2% (SD = 8.3%). Approximately 75% of veterans were fully satisfied with their transition and reported shared decision-making in the decision to transition. Rates of transitions did not decrease over the 6-month maintenance period following implementation. These data suggest that FLOW can be successfully implemented and maintained, although there was wide variation in implementation across sites. Future research should examine how to support sites that struggle with implementation.

Adult-onset multifocal kaposiform hemangioendothelioma in the bone marrow, lung, liver, and brain: a case report.

Kaposiform hemangioendothelioma (KHE), a rare form of vascular neoplasm, is typically seen in children. In this paper, we report a unique case of KHE replacing bone marrow tissue mimicking myeloproliferative neoplasm with additional involvement in the lung, liver, and brain in a 60-year-old Caucasian woman. The patient was initially seen in the hematology department for the chief complaint of epigastric pain and anemia. Abdominal magnetic resonance imaging (MRI) revealed mild splenomegaly with iron deposition secondary to extramedullary hematopoiesis. Additional workup was inconclusive. Subsequent bone marrow and lung biopsies eventually revealed bone marrow with extensive grade 3 fibrosis and multiple foci of low-grade vasoformative neoplasm in the lung suggestive of KHE. Although rare, KHE can present as an aggressive disease with indolent behavior in adults and can be distinguished from other vascular malignancies based on histopathology and imaging findings.

Care transitions from the specialty to the primary care setting: A scoping literature review of potential barriers and facilitators with implications for mental health care.

BACKGROUND, AIMS AND OBJECTIVES: This scoping review aimed to understand potential barriers and facilitators in transitioning patients from specialty to primary care settings, to inform the implementation of an intervention to promote active consideration of psychiatrically stable patients for transition from the specialty mental health setting back to primary care. METHODS: Guided by Levac and colleagues' six-stage methodological framework for conducting scoping studies, we systematically searched electronic article databases for peer-reviewed literature from January 2000 to May 2016. We included identified articles that discuss findings related to potential barriers and facilitators in transitioning patients from specialty to primary care settings. We performed descriptive and thematic analyses of results to generate emergent codes and their categorizations. RESULTS: Our database search yielded 906 unique articles, 23 of which we included in our scoping review. All but one of the included studies were conducted in North America. Identified potential barriers and facilitators spanned eight emergent themes-(i) primary care accessibility, especially in terms of timely availability of appointments, (ii) clarity in respective roles of specialty care and primary care in managing a patient, (iii) timely exchange of information, (iv) transition process management, (v) perceived ability of primary care providers to manage specialty conditions, (vi) perceived ability of patients to self-manage, (vii) leadership support and (viii) support for implementing initiatives to promote transitions. CONCLUSIONS: Findings from this scoping review enable an increased understanding of current practices and considerations regarding care transitions from specialty to primary care settings. The importance of role clarification, shared clinical information systems, confidence in care competency, and adequate organizational support to promote appropriate transitions were themes most widely reported across the reviewed studies. Few studies specifically examined the transition from specialty mental health to primary care. Future studies should account for mental health-specific symptomatic patterns and recovery trajectories, such as prevalent chronicity and frequency of relapse, in planning and conducting transitions from specialty mental health back to primary care.

Immunogenetic Determinants of Susceptibility to Head and Neck Cancer in the Million Veteran Program Cohort.

Increasing rates of human papillomavirus (HPV)-driven oropharyngeal cancer (OPC) have largely offset declines in tobacco-associated head and neck squamous cell carcinoma (HNSCC) at non-OPC sites. Host immunity is an important modulator of HPV infection, persistence, and clearance, and also of immune evasion in both virally- and nonvirally-driven cancers. However, the association between collective known cancer-related immune gene variants and HNSCC susceptibility has not been fully characterized. Here, we conducted a genetic association study in the multiethnic Veterans Affairs Million Veteran Program cohort, evaluating 16,050 variants in 1,576 immune genes in 4,012 HNSCC cases (OPC = 1,823; non-OPC = 2,189) and 16,048 matched controls. Significant polymorphisms were further examined in a non-Hispanic white (NHW) validation cohort (OPC = 1,206; non-OPC = 955; controls = 4,507). For overall HNSCC susceptibility in NHWs, we discovered and validated a novel 9q31.1 SMC2 association and replicated the known 6p21.32 HLA-DQ-DR association. Six loci/genes for overall HNSCC susceptibility were selectively enriched in African-Americans (6p21.32 HLA-G, 9q21.33 GAS1, 11q12.2 CD6, 11q23.2 NCAM1/CD56, 17p13.1 CD68, 18q22.2 SOCS6); all 6 genes function in antigen-presenting regulation and T-cell activation. Two additional loci (10q26 DMBT1, 15q22.2 TPM1) were uncovered for non-OPC susceptibility, and three loci (11q24 CRTAM, 16q21 CDH5, 18q12.1 CDH2) were identified for HPV-positive OPC susceptibility. This study underscores the role of immune gene variants in modulating susceptibility for both HPV-driven and non-HPV-driven HNSCC. Additional large studies, particularly in racially diverse populations, are needed to further validate the associations and to help elucidate other potential immune factors and mechanisms that may underlie HNSCC risk. SIGNIFICANCE: Several inherited variations in immune system genes are significantly associated with susceptibility to head and neck cancer, which could help improve personalized cancer risk estimates.

Racial and ethnic disparities in the refusal of surgical treatment in women 40 years and older with breast cancer in the USA between 2010 and 2017.

PURPOSE: Although surgical resection is the main modality of treatment for breast cancer, some patients elect to refuse the recommended surgery. We assessed racial and ethnic differences in women 40 years and older who received or refused to receive surgical treatment for breast cancer in the USA and whether racial disparities in mortality were affected by their differences in the prevalence of refusal for surgical treatment. METHODS: We studied 277,127 women with breast cancer using the Surveillance, Epidemiology, and End Results (SEER) data and performed multivariable logistic regressions to investigate the association between surgery status of breast cancer and race/ethnicity. Additionally, we performed Cox regression analyses to determine the predictors of mortality outcomes. RESULTS: Of 277,127 patients with breast cancer, 1468 (0.53%) refused to receive the recommended surgical treatment in our cohort. Non-Hispanic Black women were 112% more likely to refuse the recommended surgical treatment for breast cancer compared to their non-Hispanic White counterparts [adjusted odds ratio: 2.12, 95% confidence interval (CI) 1.82-2.47]. Women who underwent breast-conserving surgery [hazards ratio (HR) 0.15, 95% CI 0.13-0.16] and mastectomy (HR 0.21, 95% CI 0.18-0.23) had lower hazard ratios of mortality as compared to women who refused the recommended treatment after adjusting for covariates. CONCLUSION: Race/ethnicity was associated with refusal for the recommended surgery, especially among non-Hispanic Black women. Also, surgery refusal was associated with a higher risk of all-cause and breast cancer-related mortality. These disparities stress the need to tailor interventions aimed at raising awareness of the importance of following physician recommendations among minorities.

Development of a Quality Assurance Score for the Nigeria AIDS Indicator and Impact Survey (NAIIS) Database: Validation Study.

BACKGROUND: In 2018, Nigeria implemented the world's largest HIV survey, the Nigeria AIDS Indicator and Impact Survey (NAIIS), with the overarching goal of obtaining more reliable metrics regarding the national scope of HIV epidemic control in Nigeria. OBJECTIVE: This study aimed to (1) describe the processes involved in the development of a new database evaluation tool (Database Quality Assurance Score [dQAS]) and (2) assess the application of the dQAS in the evaluation and validation of the NAIIS database. METHODS: The dQAS tool was created using an online, electronic Delphi (e-Delphi) methodology with the assistance of expert review panelists. Thematic categories were developed to form superordinate categories that grouped themes together. Subordinate categories were then created that decomposed themes for more specificity. A validation score using dQAS was employed to assess the technical performance of the NAIIS database. RESULTS: The finalized dQAS tool was composed of 34 items, with a total score of 81. The tool had 2 sections: validation item section, which contains 5 subsections, and quality assessment score section, with a score of "1" for "Yes" to indicate that the performance measure item was present and "0" for "No" to indicate that the measure was absent. There were also additional scaling scores ranging from "0" to a maximum of "4" depending on the measure. The NAIIS database achieved 78 out of the maximum total score of 81, yielding an overall technical performance score of 96.3%, which placed it in the highest category denoted as "Exceptional." CONCLUSIONS: This study showed the feasibility of remote internet-based collaboration for the development of dQAS-a tool to assess the validity of a locally created database infrastructure for a resource-limited setting. Using dQAS, the NAIIS database was found to be valid, reliable, and a valuable source of data for future population-based, HIV-related studies.

The burden of oral health problems in children with mental health disorders in the United States.

OBJECTIVES: Mental health disorders (MHDs) are major public health concerns with increasing risk of morbidity and mortality among children. Oral health problems (OHPs) are receiving attention as associated comorbidities. This study assessed the burden of oral health problems in children aged 3-17 years with MHD in the United States. METHODS: Cross sectional analyses was performed using the National Survey of Children's Health database 2016-2017 containing information of 60,655,439 children. Weighted survey binomial logistic regression generating odds ratio for association between MHD and OHP were calculated. Weighted dose-response models captured incremental effects of MHD severity on oral health conditions. Population attributable risk (PAR) to quantify proportions of potentially avertable OHP as a result of intervention targeted at different levels of MHD severity were estimated. RESULTS: Prevalence of OHP among those with any MHD was 22.5 percent. Children with MHD were more likely to be non-Hispanic White, living in poorer households, and having private health insurance P < 0.001. Dose-response analyses showed children with mild MHD were 85 percent more likely [OR = 1.85 (95% CI: 1.47-2.32)], and those with moderate/severe MHD 93 percent more likely (OR = 1.93, 95% CI: 1.50-2.49) to experience OHP, compared to children without MHD. Population attributable risk (PAR) revealed that if mild and moderate/severe MHD were improved by 75 percent, OHP would be averted in 152,206 children with mild and 255,851 with moderate/severe MHD, respectively. CONCLUSION: Our results suggest that disparities persist among the pediatric population with MHD who suffer OHP in the United States.

Improving the transition of patients with mental health disorders back to primary care: A protocol for a partnered, mixed-methods, stepped-wedge implementation trial.

The current study protocol regards a partnered, mixed-methods, cluster-randomized stepped wedge trial of the implementation and effectiveness of the FLOW program. FLOW (not an acronym) is a collection of resources and strategies to assist in determining which recovered or stabilized specialty mental health (SMH) patients should transition back to primary care (PC) and tools to make the transition seamless. Transitioning appropriate patients to PC can increase access and timeliness of mental health care for newly referred mental health patients. Nine sites in one US region will be randomized to one of three waves in which they will receive implementation-facilitation to implement the FLOW program. Primary outcomes will include the reach of FLOW, provider adoption of the program, effectiveness in increasing access in SMH, implementation fidelity, and maintenance over time. A mixed-methods analysis of implementation factors associated with implementation success will also be conducted, including the following as possible predictors: staffing ratios, site resources, leadership and provider support for the program, and local champion characteristics. This study's results will provide evidence for the effectiveness of FLOW in increasing access and may provide generalizable information about characteristics of sites that are likely to be successful with implementing similar programs.

Validation of a Brief Screen to Identify Persons With Dementia at Risk for Behavioral Problems.

OBJECTIVES: Clinical assessment of persons with dementia should include potential causes of behavioral problems, including pain, depression, and caregiver-patient relationship quality. Many validated assessment tools are available; however, a brief screening tool is needed, as administering a battery of instruments is impractical in most clinical settings. We evaluated (a) the construct validity of brief screens for pain, depression, and relationship strain by examining their associations with validated measures and medication use and (b) the predictive validity of each screen and the screens as a set by examining their associations with frequency of disruptive behaviors. METHODS: Patient-caregiver dyads (n = 228) in Aggression Prevention Training for Caregivers were examined. RESULTS: There was evidence of good construct validity for each screen. The relationship screen and total number of screens endorsed were significantly associated with frequency of disruptive behaviors. CONCLUSION: The brief screens show potential for use in clinical practice.

Health Insurance Status of Pregnant Women and the Likelihood of Receipt of Antenatal Screening for HIV in Sub-Saharan Africa.

BACKGROUND: We investigated if initiating preventive care against HIV vertical transmission by antenatal HIV screening is independent of the patients' source of financial reimbursement for the care received in sub-Saharan Africa (SSA). METHODS: Using information from the WHO's Global Health Expenditure Database and the Demographic Health Surveys Database for 27 sub-Saharan countries, we used Spearman's correlation and adjusted survey logistic regression to determine the potential relationship between enrollment in health insurance and the likelihood that expectant mothers would be offered antenatal HIV screening. RESULTS: We found that expectant mothers covered by health insurance were more than twice as likely to be offered antenatal screening for HIV compared to the uninsured. The likelihood differed by the type of insurance plan the expectant mother carried. DISCUSSION: Health insurance is more of a financial tool that this study finds to be necessary to boost the uptake of preventive and therapeutic HIV care in SSA. CONCLUSION: The ensuing disparity in receiving proper care could hinder the goals of 90-90-90 and the forthcoming 95-95-95 plan in SSA.

Provider perspectives on a clinical demonstration project to transition patients with stable mental health conditions to primary care.

Research to improve access to mental healthcare often focuses on increasing timely referrals from primary care (PC) to specialty mental health (SMH). However, timely and appropriate transitions back to PC are indispensable for increasing access to SMH for new patients. We developed and implemented a formalized process to identify patients eligible for transition from SMH to PC. The FLOW intervention was piloted at a Veterans Health Administration community-based outpatient clinic. Qualitatively examine provider perspectives regarding patient transitions at initiation and termination of the FLOW project. Sixteen mental health providers and three PC staff completed qualitative interviews about the benefits and drawbacks of FLOW at initiation. Ten mental health providers and one PC staff completed interviews at 12-month follow-up. Primary benefits anticipated at initiation were that FLOW would increase access to SMH, provide acknowledgment of veterans' recovery, and differentiate between higher and lower intensity mental health services. SMH providers reported additional perceived benefits at 12-month follow-up, including decreased stress over their caseloads and increased ability to deliver efficient, effective treatment. Anticipated drawbacks at initiation were that veterans would get inconsistent care, PC could not offer the same level of care as SMH, and veterans might view transition as a rejection by their SMH provider. Perceived drawbacks were similar at 12-month follow-up, but there was less frequent endorsement. Findings highlight need for sustained and frequent provider education regarding (i) the appropriate characteristics of individuals eligible for transition and (ii) established procedures to ensure care coordination during and after transition.

FLOW: Early results from a clinical demonstration project to improve the transition of patients with mental health disorders back to primary care.

Access to mental health (MH) care is of paramount concern to U.S. health care delivery systems, including the Veterans Health Administration. To improve access, there is a need to better focus existing MH resources toward care for those most in need of specialty-level MH treatment. This article provides early results of Project FLOW's (not an acronym) approach to developing and evaluating electronic medical record (EMR)-based criteria to identify clinically stable patients and promote their effective transition from specialty MH back to primary care (PC). Implementation utilized a blended facilitation approach consistent with Integrated Promoting Action on Research Implementation in Health Services (iPARIHS). The Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework guided measurement of implementation outcomes. During FLOW, 424 unique MH patients transitioned from MH to PC; of those, only 9 (2.1%) returned to MH after that transition. Most of those patients (n = 335; 79.0%) were first identified on the MH FLOW report, but 89 (21.0%) were other MH patients. The total number of patients discharged due to recovery or stabilization was 411. The 335 patients represent 21.3% of all unique patients (n = 1,566) who met the EMR criteria during the project. The 411 recovered/stabilized patients are 16.4% of all unique MH patients (n = 2,504) treated at the site. These early results suggest that this EMR-based system, combined with sound clinical practices, can be used to identify MH patients who are candidates for transition and foster their effective transition to care management in PC. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Social Determinants of Overweight and Obesity Among Children in the United States.

BACKGROUND: Childhood obesity is one of the foremost threats to population health in the United States (U.S.) leading to the emergence of co-morbidities and increased healthcare cost. We explore the influence of selected social determinants of health (SDOH) on overweight and obesity among U.S. children. METHODS: We utilized the National Survey of Children's Health (NSCH) 2016-17 dataset for this analysis. Overweight was defined as Body Mass Index (BMI) ≥ 85th to<95th, while obesity was defined as BMI ≥95th percentile for age and sex. Based on the literature and pathway plausibility, we examined several SDOH variables as predictors of childhood overweight or obesity in the US. Survey log-binomial regression models were built to generate prevalence ratio (PR) estimates to capture the associations between SDOH and overweight or obesity. RESULTS: About 30.6 million children were surveyed of which 9.5 million (31.0%) were either overweight or obese. The likelihood of obesity was elevated among non-Hispanic Black and Hispanic children (PR = 1.53; 95% CI = 1.01-2.31) and (PR = 1.50; 95% CI = 1.18-1.90) respectively. Overweight was more frequent in younger children, children of single parents, and children who lived in a neighborhood with no amenities. Parental attainment of college education, health insurance coverage, female gender, and language spoken in home other than Spanish were protective against overweight or obesity. CONCLUSIONS AND GLOBAL HEALTH IMPLICATIONS: SDOH represent markers of overweight or obesity in children. We recommend the development of innovative interventions using SDOH risk and protective pathways as guide to address the current epidemic of childhood overweight and obesity.

Association between Intimate Partner Violence, Knowledge and Use of Contraception in Africa: Comparative Analysis across Five African Regions.

BACKGROUND OR OBJECTIVES: Intimate partner violence (IPV) against women is common globally, and is associated with several adverse consequences. This study provides a comparative analysis of potential regional differences in the association between IPV and knowledge and use of contraceptives within Africa. METHODS: A multi-country cross-sectional study was conducted using data on women of reproductive age 15-49 years from the Demographic and Health Surveys covering five African regions. Exposure and outcome variables were IPV and reproductive literacy (comprising modern contraception knowledge and contraception usage) respectively. We used survey log-binomial regression models to generate prevalence ratios that estimated the association between IPV versus knowledge and usage of modern contraception. RESULTS: Overall IPV prevalence in Africa was 30.8% with notable regional differences. Demographic, socioeconomic, and reproductive history markers of IPV were more pronounced in younger women, rural residents, women of low socioeconomic status and those with copious knowledge but poor usage of modern contraception. The level of knowledge of contraception was 84% greater among African women who were victims of IPV compared to their counterparts who were not victims of IPV (p < 0.0001). IPV was not associated with actual usage of modern contraception (p = 0.21). CONCLUSION AND GLOBAL HEALTH IMPLICATIONS: IPV against women in Africa may incentivize knowledge seeking of modern contraception as protective mechanisms. Regional variations notwithstanding, understanding the existing and new characteristics predictive of IPV may inform policy development, resource allocation and prevention of IPV globally.

Oral Health Problems among Children with Neurodevelopmental Disorders in the United States.

Children with neurodevelopmental disabilities (NDD) suffer poor oral health problems (OHP) leading to adverse health outcomes. We examined the association between NDD and OHP among children in the United States (US) ages 3-17 years using data from the National Survey of Children's Health (NSCH) 2016-17. The prevalence of OHP was 19.1%. Children with NDD had about 40% greater likelihood of poor oral health compared to their non-NDD counterparts (p <0.0001). Living at or above 200%-300% of the federal poverty level (FPL), private insurance coverage, and living with a least a college educated adult were found to be protective factors against poor oral health among children.