Cost, Quality, and Utilization After Hospital-Physician and Hospital-Post Acute Care Vertical Integration: A Systematic Review.

Vertical integration of health systems-the common ownership of different aspects of the health care system-continues to occur at increasing rates in the United States. This systematic review synthesizes recent evidence examining the association between two types of vertical integration-hospital-physician (n = 43 studies) and hospital-post-acute care (PAC; n = 10 studies)-and cost, quality, and health services utilization. Hospital-physician integration is associated with higher health care costs, but the effect on quality and health services utilization remains unclear. The effect of hospital-PAC integration on these three outcomes is ambiguous, particularly when focusing on hospital-SNF integration. These findings should raise some concern among policymakers about the trajectory of affordable, high-quality health care in the presence of increasing hospital-physician vertical integration but perhaps not hospital-PAC integration.

Perspectives from persons living with dementia and their caregivers on emergency department visits, care transitions, and outpatient follow-up: A qualitative study.

BACKGROUND: Persons living with dementia (PLWD) experience frequent and costly emergency department (ED) visits, with poor outcomes attributed to suboptimal care and postdischarge care transitions. Yet, patient-centered data on ED care experiences and postdischarge needs are lacking. The objective of this study was to examine the facilitators and barriers to successful ED care and care transitions after discharge, according to PLWD and their caregivers. METHODS: We conducted a qualitative study involving ED patients ages 65 and older with confirmed or suspected dementia and their caregivers. The semistructured interview protocol followed the National Quality Forum's ED Transitions of Care Framework and addressed ED care, care transitions, and outpatient follow-up care. Interviews were conducted during an ED visit at an urban, academic ED. Traditional thematic analysis was used to identify themes. RESULTS: We interviewed 11 patients and 19 caregivers. Caregivers were more forthcoming than patients about facilitators and challenges experienced. Characteristics of the patients' condition (e.g., resistance to care, forgetfulness), the availability of family resources (e.g., caregiver availability, primary care access), and system-level factors (e.g., availability of timely appointments, hospital policies tailored to persons with dementia) served as facilitators and barriers to successful care. Some resources that would ameliorate care transition barriers could be easily provided in the ED, for example, offering clear discharge instructions and care coordination services and improving patient communication regarding disposition timeline. Other interventions would require investment from other parts of the health care system (e.g., respite for caregivers, broader insurance coverage). CONCLUSIONS: ED care and care transitions for PLWD are suboptimal, and patient-level factors may exacerbate existing system-level deficiencies. Insight from patients and their caregivers may inform the development of ED interventions to design specialized care for this patient population. This qualitative study also demonstrated the feasibility of conducting ED-based studies on PLWD during their ED visit.

Qualitative Evaluation Informs the Implementation of a Telehealth Program to Manage Chronic Pain.

In response to the opioid epidemic and high rates of chronic pain among the veteran population, the U.S. Department of Veterans Affairs implemented the TelePain-Empower Veterans Program (EVP), a nonpharmacological pain management program for veterans. Delivered virtually, TelePain-EVP incorporates integrated health components (Whole Health, Acceptance and Commitment Therapy, and Mindful Movement) through interdisciplinary personalized coaching. The objective of this quality improvement project was to evaluate the implementation of TelePain-EVP to identify determinants to implementation, benefits and challenges to participation, and recommendations for future direction. We used a qualitative descriptive design to conduct semistructured telephone interviews with TelePain-EVP leaders (n = 3), staff (n = 10), and veterans (n = 22). The interview guides aligned with the Consolidated Framework for Implementation Research (CFIR). Thematic content analysis organized and characterized findings. Several CFIR domains emerged as determinants relevant to program implementation, including innovation (eg, design); individuals (eg, deliverers, recipients); inner (eg, communications) and outer settings (eg, local conditions); and implementation process (eg, reflecting and evaluating). Identified determinants included facilitators (eg, virtual delivery) and barriers (eg, staff shortages). Participants reported improvements in pain management coping skills, interpersonal relationships, and sense of community, but no self-reported reductions in pain or medication use. Program improvement recommendations included using centralized staff to address vacancies, collecting electronic data, offering structured training, and providing course materials to veteran participants. Qualitative data can inform the sustained implementation of TelePain-EVP and other similar telehealth pain management programs. These descriptive data should be triangulated with quantitative data to objectively assess participant TelePain-EVP outcomes and associated participant characteristics. PERSPECTIVE: A qualitative evaluation of a telehealth program to manage chronic pain, guided by the CFIR framework, identified determinants of program implementation. Additionally, participants reported improvements in pain management coping skills, interpersonal relationships, and sense of community, but no self-reported reductions in pain or medication use.

Declining Participation in Primary Care Quality Improvement Research: A Qualitative Study.

PURPOSE: There are numerous supportive quality improvement (QI) projects to facilitate the implementation of evidence-based practices in primary care, but recruiting physician practices to join these projects is challenging, costly, and time consuming. We aimed to identify factors leading primary care practices to decline participation in QI projects, and strategies to improve the feasibility and attractiveness of QI projects in the future. METHODS: For this qualitative study, we contacted 109 representatives of practices that had declined participation in 1 of 4 Agency for Healthcare Research and Quality-funded EvidenceNOW projects. The representatives were invited to participate in a 15-minute interview or complete a 5-question questionnaire. Thematic analysis was used to organize and characterize findings. RESULTS: Representatives from 31 practices (28.4% of those contacted) responded. Overwhelmingly, respondents indicated that staff turnover, staffing shortages, and general time constraints, exacerbated by the pandemic, prevented participation in the QI projects. Challenges with electronic health records, an expectation of greater financial compensation for participation, and confidence in the practices' current care practices were secondary reasons for declining participation. Tying participation to value-based programs and offering greater compensation were identified as strategies to facilitate recruitment. None of the respondents' recommendations, however, addressed the primary issues of staffing challenges and time constraints. CONCLUSIONS: Staffing challenges and general time constraints, exacerbated by the pandemic, are compromising primary care practices' ability to engage in QI research projects. To encourage participation, policy makers should consider direct supports for primary care, which may also help to alleviate burnout.

Rationale and design for Healthy Hearts for Michigan (HH4M): A pragmatic single-arm hybrid effectiveness-implementation study.

Background: The burden of cardiovascular disease (CVD) is particularly high in several US states, which include the state of Michigan. Hypertension and smoking are two major risk factors for mortality due to CVD. Rural Michigan is disproportionally affected by CVD and by primary care shortages. The Healthy Hearts for Michigan (HH4M) study aims to promote hypertension management and smoking cessation through practice facilitation and quality improvement efforts and is part of the multi-state EvidenceNOW: Building State Capacity initiative to provide external support to primary care practices to improve care delivery. Methods: Primary care practices in rural and underserved areas of Michigan were recruited to join HH4M, a pragmatic, single-arm hybrid Type 2 effectiveness-implementation study during which practice facilitation was delivered at the practice level for 12 months, followed by a 3-month maintenance period. Results: Fifty-four practices were enrolled over a 12-month recruitment period. At baseline, the mean proportion (standard deviation) of patients at the practice level meeting the clinical quality measures were: blood pressure, 0.72 (0.12); tobacco screening, 0.80 (0.30); tobacco cessation intervention, 0.57 (0.28); tobacco screening and cessation intervention: 0.78 (0.26). Conclusion: This three-year research program will evaluate the ability of rural and medically underserved primary care practices to implement the quality improvement model by identifying drivers of and barriers to sustainable implementation, and test whether the model improves (a) blood pressure control and (b) tobacco use screening and cessation.

For-Profit Businesses as Public Health Partners to Promote COVID-19 Vaccination: A Multiple Case Study.

OBJECTIVE: This study aimed to describe the actions used by health professionals employed by large, for-profit businesses to promote uptake of COVID-19 vaccines, and factors that facilitated and hindered coordination with local public health leaders. METHODS: In this qualitative multiple case study, we conducted telephone interviews with health professionals from businesses, health department leaders, and others who could provide information about local vaccination efforts (e.g., emergency managers, reporters). RESULTS: Businesses' self-interest (i.e., need to keep employees working), vaccine mandates, and characteristics of the businesses (e.g., ownership, expertise) facilitated leadership in COVID-19 vaccination efforts. Coordination with local health departments was influenced by the resources of the local health department and history of collaboration. CONCLUSIONS: Health professionals employed by large businesses can serve as key public health partners, but their role is shaped by characteristics of the businesses and communities.

An Approach to Evaluating Multisector Partnerships to Support Evidence-Based Quality Improvement in Primary Care.

BACKGROUND: Quality improvement (QI) interventions in primary care are increasingly designed and implemented by multisector partnerships, yet little guidance exists on how to best monitor or evaluate these partnerships. The goal of this project was to describe an approach for evaluating the development and effectiveness of a multisector partnership using data from the first year of the Healthy Hearts for Michigan (HH4M) Cooperative, a multisector partnership of nine organizations tasked with designing and implementing evidence-based QI strategies for hypertension management and tobacco cessation in 50 rural primary care practices. METHODS: The researchers developed a 49-item online survey focused on factors that facilitate or hinder multisector partnerships, drawing on implementation science and partnership, engagement, and collaboration research. The team surveyed all 44 members of the HH4M Cooperative (79.5% response rate) and conducted interviews with 14 members. The interviews focused on implementation phase-specific goals, accomplishments, and challenges. Descriptive analysis was used for the survey results, and thematic analysis for the interview data. RESULTS: Respondents reported strong overall performance by the Cooperative during its first year, which facilitated the successful completion of several intervention design tasks. Strengths included having a clear purpose and trust and respect among members. Areas for improvement included a need for common terminology, clarification of roles and functions, and improvement in communication across workgroups. Lack of engagement from physician practices due to capacity constraints, exacerbated by the COVID-19 pandemic, was the Cooperative's biggest challenge. CONCLUSION: This multimethod approach to evaluating the development and effectiveness of a multisector partnership yielded practical, actionable feedback to program leaders.

Communities with an anchor institution have higher coronavirus vaccination rates.

PURPOSE: Anchor institutions ("anchors") are large employers, rooted in a community by reason of mission, capital, or relationships. Many anchors have encouraged coronavirus vaccination for employees and their families. Our objective was to determine whether the presence of an anchor was associated with a higher county-level vaccination rate. METHODS: A cross-sectional study focused on 745 small- and mid-sized US counties. We used data from the Centers for Disease Control and Prevention, Reference USA's US Business Database, Economic Innovation Group's Distressed Communities Index database, 2021 County Health Ratings and Rankings, 2020 US Presidential Election popular vote data, and National Center for Health Statistics urban-rural classification data. We constructed 3 explanatory variables of interest: a binary variable indicating whether the county had an anchor; a continuous variable representing the number of anchors within a county; and the percent of all workers in the county who were employed by an anchor. Multivariable linear regression models were adjusted for race/ethnicity, political party allegiance, rurality, economic distress, and prevalence of smoking and adult obesity. FINDINGS: Counties with an anchor had vaccination rates 2.31 (P<.01) percentage points higher than those without an anchor. The number of anchors in a county was also significantly associated with higher vaccination rates. CONCLUSIONS: Efforts by anchors to encourage vaccination may have been successful, and that anchors may be well positioned to amplify public health messages. However, the influence and efforts of anchors to increase vaccination did not fully mitigate disparities in vaccination rates by race, ethnicity, and political party allegiance.

Metadata Correction: Identifying Contextual Factors and Strategies for Practice Facilitation in Primary Care Quality Improvement Using an Informatics-Driven Model: Framework Development and Mixed Methods Case Study.

[This corrects the article DOI: 10.2196/32174.].

Identifying Contextual Factors and Strategies for Practice Facilitation in Primary Care Quality Improvement Using an Informatics-Driven Model: Framework Development and Mixed Methods Case Study.

BACKGROUND: The past decade has seen increasing opportunities and efforts to integrate quality improvement into health care. Practice facilitation is a proven strategy to support redesign and improvement in primary care practices that focuses on building organizational capacity for continuous improvement. Practice leadership, staff, and practice facilitators all play important roles in supporting quality improvement in primary care. However, little is known about their perspectives on the context, enablers, barriers, and strategies that impact quality improvement initiatives. OBJECTIVE: This study aimed to develop a framework to enable assessment of contextual factors, challenges, and strategies that impact practice facilitation, clinical measure performance, and the implementation of quality improvement interventions. We also illustrated the application of the framework using a real-world case study. METHODS: We developed the TITO (task, individual, technology, and organization) framework by conducting participatory stakeholder workshops and incorporating their perspectives to identify enablers and barriers to quality improvement and practice facilitation. We conducted a case study using a mixed methods approach to demonstrate the use of the framework and describe practice facilitation and factors that impact quality improvement in a primary care practice that participated in the Healthy Hearts in the Heartland study. RESULTS: The proposed framework was used to organize and analyze different stakeholders' perspectives and key factors based on framework domains. The case study showed that practice leaders, staff, and practice facilitators all influenced the success of the quality improvement program. However, these participants faced different challenges and used different strategies. The framework showed that barriers stemmed from patients' social determinants of health, a lack of staff and time, and unsystematic facilitation resources, while enablers included practice culture, staff buy-in, implementation of effective practice facilitation strategies, practice capacity for change, and shared complementary resources from similar, ongoing programs. CONCLUSIONS: Our framework provided a useful and generalizable structure to guide and support assessment of future practice facilitation projects, quality improvement initiatives, and health care intervention implementation studies. The practice leader, staff, and practice facilitator all saw value in the quality improvement program and practice facilitation. Practice facilitators are key liaisons to help the quality improvement program; they help all stakeholders work toward a shared target and leverage tailored strategies. Taking advantage of resources from competing, yet complementary, programs as additional support may accelerate the effective achievement of quality improvement goals. Practice facilitation-supported quality improvement programs may be opportunities to assist primary care practices in achieving improved quality of care through focused and targeted efforts. The case study demonstrated how our framework can support a better understanding of contextual factors for practice facilitation, which could enable well-prepared and more successful quality improvement programs for primary care practices. Combining implementation science and informatics thinking, our TITO framework may facilitate interdisciplinary research in both fields.

Employer-Led Strategies to Improve the Value of Health Spending: A Systematic Review.

OBJECTIVE: To systematically review studies that evaluated the impact of employer-led efforts in the United States to improve the value of health spending, where employers have implemented changes to their health benefits to reduce costs while improving or maintaining quality. METHODS: We included all studies of employer-led health benefit strategies that reported outcomes for both employer health spending and employee health outcomes. RESULTS: Our search returned 44 studies of employer health benefit changes that included measures of both health spending and quality. The most promising efforts were those that lowered or eliminated cost sharing for primary care or medications for chronic illnesses. High deductible health plans with a savings option appeared less promising. CONCLUSIONS: More research is needed on the characteristics and contexts in which these benefit changes were implemented, and on actions that address employers' current concerns.

Cost-Effectiveness of Hearing Screening in Older Adults: A Scoping Review.

OBJECTIVES: Age is the most common predictor of hearing loss; however, many older adults are not screened. Hearing screening could improve healthcare access, participation, and outcomes. Establishing whether hearing screening in older adults is cost-effective could improve the availability and utilization of screening. METHODS: We searched nine databases in January 2020. Studies with populations aged 50+ and provided data on the cost-effectiveness of hearing screening were included in the review. RESULTS: Five studies met the inclusion criteria and all found hearing screening programs to be cost-effective compared to no hearing screening, regardless of screening method (i.e., instrument or strategy). The maximum number of repeated screenings, coupled with younger ages, was most cost-effective. DISCUSSION: This review suggests that hearing screening in older adults is cost-effective, however, the evidence is limited. There is pressing need for research focused on economic impacts of hearing healthcare in older adults to inform research, policy and practice.

Identification and quantification of oligogenic loss-of-function disorders.

PURPOSE: Monogenic disorders can present clinically heterogeneous symptoms. We hypothesized that in patients with a monogenic disorder caused by a large deletion, frequently additional loss-of-function (LOF)-intolerant genes are affected, potentially contributing to the phenotype. METHODS: We investigated the LOF-intolerant gene distribution across the genome and its association with benign population and pathogenic classified deletions from individuals with presumably monogenic disorders. For people with presumably monogenic epilepsy, we compared Human Phenotype Ontology terms in people with large and small deletions. RESULTS: We identified LOF-intolerant gene dense regions that were enriched for ClinVar and depleted for population copy number variants. Analysis of data from >143,000 individuals with a suspected monogenic disorder showed that 2.5% of haploinsufficiency disorder-associated deletions can affect at least 1 other LOF-intolerant gene. Focusing on epilepsy, we observed that 13.1% of pathogenic and likely pathogenic ClinVar deletions <3 megabase pair, covering the diagnostically most relevant genes, affected at least 1 additional LOF-intolerant gene. Those patients have potentially more complex phenotypes with increasing deletion size. CONCLUSION: We could systematically show that large deletions frequently affected admditional LOF-intolerant genes in addition to the established disease gene. Further research is needed to understand how additional potential disease-relevant genes influence monogenic disorders to improve clinical care and the efficacy of targeted therapies.

Closure of Anchor Businesses Reduced COVID-19 Transmission During the Early Months of the Pandemic.

OBJECTIVES: To investigate the relationship between the closure of "anchor businesses" - manufacturing plants and distribution centers employing >1000 workers - and the daily, county-level COVID-19 rate between March 1, 2020 and May 31, 2020. METHODS: We conducted a comparative, interrupted time series analysis of publicly available county-level data. Our main variable of interest was closure, indicating whether one or more of the anchor businesses within the county experienced a full or partial closure of at least 22 days (main analysis) or at least 1 day (sensitivity analyses). RESULTS: Closure of an anchor business was associated with 142 fewer positive COVID-19 tests per 100,000 population over a 40-day period. Even short-term and partial closures were associated with reduced spread. CONCLUSIONS: Temporary closure of anchor businesses appears to have slowed, but not completely contained, the spread of COVID-19.

Implementation outcomes of HIV self-testing in low- and middle- income countries: A scoping review.

INTRODUCTION: HIV self-testing (HIV-ST) is an effective means of improving HIV testing rates. Low- and middle-income countries (LMIC) are taking steps to include HIV-ST into their national HIV/AIDS programs but very few reviews have focused on implementation in LMIC. We performed a scoping review to describe and synthesize existing literature on implementation outcomes of HIV-ST in LMIC. METHODS: We conducted a systematic search of Medline, Embase, Global Health, Web of Science, and Scopus, supplemented by searches in HIVST.org and other grey literature databases (done 23 September 2020) and included articles if they reported at least one of the following eight implementation outcomes: acceptability, appropriateness, adoption, feasibility, fidelity, cost, penetration, or sustainability. Both quantitative and qualitative results were extracted and synthesized in a narrative manner. RESULTS AND DISCUSSION: Most (75%) of the 206 included articles focused on implementation in Africa. HIV-ST was found to be acceptable and appropriate, perceived to be convenient and better at maintaining confidentiality than standard testing. The lack of counselling and linkage to care, however, was concerning to stakeholders. Peer and online distribution were found to be effective in improving adoption. The high occurrence of user errors was a common feasibility issue reported by studies, although, diagnostic accuracy remained high. HIV-ST was associated with higher program costs but can still be cost-effective if kit prices remain low and HIV detection improves. Implementation fidelity was not always reported and there were very few studies on, penetration, and sustainability. CONCLUSIONS: Evidence supports the acceptability, appropriateness, and feasibility of HIV-ST in the LMIC context. Costs and user error rates are threats to successful implementation. Future research should address equity through measuring penetration and potential barriers to sustainability including distribution, cost, scale-up, and safety.

The Impact of Shift Work and Long Work Hours on Employers' Health Care Costs.

OBJECTIVE: To estimate the additional health care costs incurred by two U.S. manufacturing companies due to their policies related to shift work and long work hours. METHODS: We applied risk ratios from the published literature to data on 2647 workers from Company A and 1346 workers from Company B to estimate the excess cases of several chronic conditions in the worker population due to shift work and long work hours. We estimated the annual health care costs incurred by the companies by applying Medicare cost data. RESULTS: Excess annual health care costs related to shift work totaled $1,394,365 and $300,297 for Companies A and B, respectively. Excess annual costs related to long work hours totaled $231,293 and $107,902 for Companies A and B, respectively. CONCLUSIONS: Excess health care costs related to shift work and long work hours is substantial, but may not be large enough to compel companies to alter their work scheduling policies.

A systematic review of the effectiveness of employer-led interventions for drug misuse.

AIMS: Employers in the United States incur substantial costs associated with substance use disorders. Our goal was to examine the effectiveness of employer-led interventions to reduce the adverse effects of drug misuse in the workplace. METHODS: We conducted a systematic review of studies that evaluated the effectiveness of recommended workplace interventions for opioids and related drugs: employee education, drug testing, employee assistance programs, supervisor training, written workplace drug-free policy, and restructuring employee health benefit plans. We searched PubMed MEDLINE, EMBASE (embase.com), PsycINFO (Ebsco), ABI Inform Global, Business Source Premier, EconLit, CENTRAL, Web of Science (Thomson Reuters), Scopus (Elsevier), Proquest Dissertations, and Epistemonikos from inception through May 8, 2019, with no date or language restrictions. We included randomized controlled trials, quasi-experimental studies, and cross-sectional studies with no language or date restrictions. The Downs and Black questionnaire was used to assess the quality of included studies. The results were reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. RESULTS: In all, 27 studies met our inclusion criteria and were included in the systematic review. Results were mixed, with each intervention shown to be effective in at least one study, but none showing effectiveness in over 50% of studies. Studies examining the impact of interventions on workplace injuries or accidents were more commonly reported to be effective. Although four studies were randomized controlled trials, the quality of all included studies was "fair" or "poor." CONCLUSIONS: Despite the opioid epidemic, high-quality studies evaluating the effectiveness of employer-led interventions to prevent or reduce the adverse effects of substance use are lacking. Higher quality and mixed methods studies are needed to determine whether any of the interventions are generalizable and whether contextual adaptations are needed. In the meantime, there is a reason to believe that commonly recommended, employer-led interventions may be effective in some environments.

Shift work and long work hours and their association with chronic health conditions: A systematic review of systematic reviews with meta-analyses.

BACKGROUND: Previous reviews have demonstrated that shift work and long work hours are associated with increased risk for chronic conditions. However, these reviews did not comprehensively assessed the body of evidence, and some were not conducted in a systematic manner. A better understanding of the health consequences of shift work and long work hours will aid in creating policy and practice recommendations. This review revisits the epidemiologic evidence on the association of shift work and long work hours with chronic conditions with particular emphasis on assessing the quality of the evidence. METHODS AND FINDINGS: We conducted a systematic review of systematic reviews with meta-analyses (SR-MA) that assessed the link between shift work or long work hours and chronic conditions (PROSPERO CRD42019122084). We evaluated the risk of bias of each SR-MA using AMSTAR v2 and assessed the overall evidence for each condition using the GRADE approach. We included 48 reviews covering cancers, cardiovascular diseases, metabolic syndrome and related conditions, pregnancy complications, depression, hypertension, and injuries. On average, only 7 of 16 AMSTAR items were fulfilled. Few SR-MAs had a registered protocol and nearly all failed to conduct a comprehensive search. We found moderate grade evidence linking shift work to breast cancer and long work hours to stroke. We found low grade evidence linking both shift work and long work hours with low to moderate increase in risk for some pregnancy complications and cardiovascular diseases. Low grade evidence also link long work hours and depression. CONCLUSIONS: Moderate grade evidence suggest that shift work and long work hours increase the risk of breast cancer and stroke, but the evidence is unclear on other chronic conditions. There is a need for high-quality studies to address this gap. Stakeholders should be made aware of these increased risks, and additional screening and prevention should be considered, particularly for workers susceptible to breast cancer and stroke.

Effect of Baseline Symptom Manifestations on Retention in Care and Treatment among HIV-Infected Patients in Nigeria.

BACKGROUND: Symptom management is an important component of HIV care. But symptom patterns and how they affect engagement with HIV care and treatment services have not been adequately explored in the era of increased HIV treatment scale-up. We investigated the relationship between symptom patterns among people living with HIV (PLHIV) and 12 months retention in care, within the context of other clinical and demographic characteristics. METHODS: Retrospective cohort analysis of 5114 PLHIV receiving care within a large HIV treatment program in Nigeria. We assessed the prevalence and burden of baseline symptoms reported during routine clinic visits from January 2015 to December 2017. Multivariable regression was used to identify relationships between 12-month retention and symptom dimensions (prevalence and burden) while controlling for demographic and other clinical variables. RESULTS: Increasing symptom burden was associated with higher likelihood of retention at 12 months (adjusted odds ratio [aOR] = 1.19 [95% confidence interval, CI: 1.09-1.29]; P < .001) as was the reporting of skin rashes/itching symptom (aOR = 2.59 [95% CI: 1.65-4.09]; P < .001). Likelihood of retention reduced with increasing World Health Organization (WHO) Clinical staging, with CD4 ≥500 cells/mL and self-reported heterosexual mode of HIV transmission. Conclusions: Symptom dimensions and standardized clinical/immunological measures both predicted retention in care, but effects differed in magnitude and direction. Standardized clinical/immunological measures in HIV care (eg, WHO clinical staging and CD4 count categories) can mask important differences in how PLHIVs experience symptoms and, therefore, their engagement with HIV care and treatment. Symptom management strategies are required alongside antiretroviral treatment to improve outcomes among PLHIV, including retention in care.

A Qualitative Exploration of Shift Work and Employee Well-Being in the US Manufacturing Environment.

OBJECTIVE: Describe manufacturing workers' perceptions of the effect of shift work, following the Framework for Worker Well-Being. METHODS: Eight focus groups and 43 interviews were conducted across four large manufacturing plants. Thematic analysis was used to analyze the data within each of the five domains of the Framework: physical environment and safety climate; workplace policies and culture; health status; work evaluation and experience; and home, community, and society. RESULTS: Respondents described shift work as detrimental to well-being across four of the five Framework domains. The exception was in the workplace policies and culture domain, where some respondents described shift work as necessary, fair, and financially beneficial. CONCLUSIONS: Shift work negatively influences worker well-being in a holistic way. Employers could consider reconfiguring workplace wellness benefits to transcend the boundaries of the workplace and better support workers and their families.