Strategies to Improve Patient-Centered Care for Drug Use-Associated Infective Endocarditis: JACC Focus Seminar 2/4.

Drug use-associated infective endocarditis (DUA-IE) is a major cause of illness and death for people with substance use disorder (SUD). Investigations to date have largely focused on advancing the care of patients with DUA-IE and included drug use disorder treatment, decisions about surgery, and choice of antibiotics during the period of hospitalization. Transitions from hospital to outpatient care are relatively unstudied and frequently a key factor of uncontrolled infection, continued substance use, and death. In this paper, we review the evidence supporting cross-disciplinary care for people with DUA-IE and highlight domains that need further clinician, institutional, and research investment in clinicians and institutions. We highlight best practices for treating people with DUA-IE, with a focus on addressing health disparities, meeting health-related social needs, and policy changes that can support care for people with DUA-IE in the hospital and when transitioning to the community.

Medicaid Inmate Exclusion Policy and Infectious Diseases Care for Justice-Involved Populations.

The Medicaid Inmate Exclusion Policy (MIEP) prohibits using federal funds for ambulatory care services and medications (including for infectious diseases) for incarcerated persons. More than one quarter of states, including California and Massachusetts, have asked the federal government for authority to waive the MIEP. To improve health outcomes and continuation of care, those states seek to cover transitional care services provided to persons in the period before release from incarceration. The Massachusetts Sheriffs' Association, Massachusetts Department of Correction, Executive Office of Health and Human Services, and University of Massachusetts Chan Medical School have collaborated to improve infectious disease healthcare service provision before and after release from incarceration. They seek to provide stakeholders working at the intersection of criminal justice and healthcare with tools to advance Medicaid policy and improve treatment and prevention of infectious diseases for persons in jails and prisons by removing MIEP barriers through Section 1115 waivers.

A health literacy analysis of online patient-directed educational materials about mycobacterium avium complex.

Introduction: Mycobacterium avium complex (MAC) is a complex lung infection requiring multi-disciplinary approach and management. Due to limited clinician-patient interactions, clinicians may refer patients to online resources to learn about the diagnosis, prognosis, and treatment of MAC. The American Medical Association (AMA) recommends educational materials be written at a sixth-grade reading level and the National Institutes of Health (NIH) recommends that patient education materials be written at an eighth-grade reading level; however, several evaluations found these materials inaccessible due to high literacy levels. To date, there has never been a health literacy assessment of MAC patient education materials. The study aims to assess the health literacy of online patient education materials about MAC. Methods: The patient education materials were evaluated for readability, actionability, understandability and clarity. Readability was assessed through the Flesch-Kincaid Grade Level Scale (FkGL), SMOG Index, Coleman Liau Index (CLI), Gunning Fog Index (GFI), and Automated Readability Index (ARI). Actionability and understandability was evaluated using the Patient Education Materials Assessment Tool (PEMAT). The Centers for Disease Control (CDC) Clear Communication Index (CCI) was used to assess clarity. Results: Ten patient education resources were evaluated: CDC, Cleveland Clinic, Mayo Clinic, JAMA, American Thoracic Society (ATS), National Jewish Health, UpToDate, CHEST, WebMD, and Medline. The mean readability scores were as follows: FkGL (9.76), SMOG index (9.82), CLI (13.54), GFI (11.66), ARI (9.15). Four patient education materials were written at a sixth-grade reading level and eight patient education materials were written at an eighth-grade reading level. The majority of the materials received a passing score for understandability but failed to achieve a passing score for actionability. Cleveland Clinic, JAMA, and ATS all received a passing clarity score, indicating that they are easy to read. No patient education materials were available on UpToDate. Conclusion: Most patient education materials scored poorly for actionability and clarity while scoring highly for readability and understandability. This study should serve as a guide for clinicians interested in offering online education materials to their patients. Increasing access to readable MAC educational materials should be a priority for those working at the intersection of public health, clinical care, and communications.

Effect of Antibiotic Administration Before Joint Aspiration on Synovial Fluid White Blood Cell Count in Native Joint Septic Arthritis.

Background: This study was performed to assess the impact of preaspiration antibiotics on synovial fluid analysis and timing of operative treatment in native-joint septic arthritis. Methods: We performed a retrospective record review of adult patients from an urban level 1 trauma center with native joint septic arthritis in 2015-2019, identified by means of codes from the International Classification of Diseases (Ninth Revision and Tenth Revision). Univariate and multivariate analyses were performed to determine whether antibiotics were associated with lower synovial fluid white blood cell counts (WBCs), the percentage of polymorphonuclear neutrophil (PMNs), and rate of culture positivity. Secondary analysis included time elapsed from aspiration to surgery. Results: Of the 126 patients with septic joints included, nearly two-thirds (n = 80 [63.5%]) received antibiotics before joint aspiration. The synovial fluid WBC count, percentage of PMNs, and rate of culture positivity were significantly lower in patients who received preaspiration antibiotics than in those who did not (mean WBC count, 51 379.1/µL [standard deviation, 52 576.3/µL] vs 92 162.7/µL [59 330.6/µL], respectively [P < .001]; PMN percentage, 83.6% [20.5%] vs 91.9% [6.0%; P = .01]; and culture positivity, 32.5% vs 59.1% [P = .008]). Multivariable analyses revealed that these associations remained after controlling for potential confounders (change in PMNs, -42 784.60/µL [95% confidence interval, -65 355/µL to -20 213.90/µL [P < .001]; change in PMNs, -7.8% [-13.7% to -1.8%] [P = .01]; odds ratio, 0.39 [.18-.87; P = .02). Patients with a synovial fluid WBC count ≤50 000/µL experienced significant delay in time from joint aspiration to operative intervention (mean [standard deviation], 10.5 [11.3] vs 17.9 [17.2] hours; P = .02). Conclusions: The administration of antibiotics before joint aspiration for suspected septic arthritis appears to decrease the synovial fluid WBC count, the percentage of PMNs, and the rate of culture positivity. Efforts to limit antibiotic administration before joint aspiration are important to minimize diagnostic dilemmas and circumvent treatment delays.

Racial differences in testing for infectious diseases: An analysis of jail intake data.

HIV and hepatitis C virus (HCV) testing for all people in jail is recommended by the CDC. In the community, there are barriers to HIV and HCV testing for minoritized people. We examined the relationship between race and infectious diseases (HIV, HCV, syphilis) testing in one Massachusetts jail, Middlesex House of Corrections (MHOC). This is a retrospective analysis of people incarcerated at MHOC who opted-in to infectious diseases testing between 2016-2020. Variables of interest were race/ethnicity, self-identified history of psychiatric illness, and ever having experienced restrictive housing. Twenty-three percent (1,688/8,467) of people who were incarcerated requested testing at intake. Of those, only 38% received testing. Black non-Hispanic (25%) and Hispanic people (30%) were more likely to request testing than white people (19%). Hispanic people (16%, AOR 1.69(1.24-2.29) were more likely to receive a test result compared to their white non-Hispanic (8%, AOR 1.54(1.10-2.15)) counterparts. Black non-Hispanic and Hispanic people were more likely to opt-in to and complete infectious disease testing than white people. These findings could be related to racial disparities in access to care in the community. Additionally, just over one-third of people who requested testing received it, underscoring that there is room for improvement in ensuring testing is completed. We hope our collaborative efforts with jail professionals can encourage other cross-disciplinary investigations.

Implementation of a bundle to improve HIV testing during hospitalization for people who inject drugs.

Background: Increased HIV testing is essential to ending the HIV epidemic. People who inject drugs (PWID) are among the highest risk for HIV infection. Previous research at Tufts Medical Center identified low HIV testing rates in hospitalized PWID. Our research team aimed to identify and overcome barriers to inpatient HIV screening of PWID using implementation science methods. Methods: Stakeholders were engaged to gather perspectives on barriers and facilitators of HIV testing. A PWID care bundle was developed and implemented, which included (1) HIV screening; (2) hepatitis A, B, and C testing and vaccination; (3) medications for opioid use disorder; and (4) naloxone prescription. Strategies from all nine Expert Recommendations for Implementing Change (ERIC) clusters guided the implementation plan. Stakeholder feedback was gathered throughout implementation, and implementation outcomes of acceptability and feasibility were assessed. Results: PWID overall felt comfortable with HIV testing being offered while hospitalized. Clinicians cited that the main barriers to HIV testing were discomfort and confusion around consenting requirements. Many resident physicians surveyed reported that, at times, they forgot HIV testing for PWID. Overall, though, resident physicians felt that the PWID bundle was useful and did not distract from other patient care responsibilities. Conclusions: Engagement of key stakeholders to increase HIV testing in an inpatient setting led to the implementation of a PWID bundle, which was feasible and acceptable. Bundling evidence-informed care elements for inpatient PWID should be investigated further.

People who inject drugs (PWID) are at an increased risk of contracting HIV. HIV testing is a key strategy to stop the spread of HIV. Our study created a bundle of services and tests to offer to all PWID who were admitted to the hospital. The bundle included HIV testing; hepatitis A, B, and C testing and vaccination; medications for opioid use disorder; and prescription for Narcan, a medication that can reverse opioid overdose. We then asked doctors and patients how they felt about the bundle and any barriers and facilitators that they predicted for expanding HIV testing to PWID while admitted to the hospital. Patients were accepting of expanding HIV testing, and resident physicians felt it was important as well and was a manageable addition to their list of responsibilities. However, the most likely part of the bundle to be forgotten was HIV testing. This study lays the groundwork for bundling services for PWID while they are hospitalized. We also highlight areas for future exploration.

Low frequency of allergy referral for penicillin allergy evaluation in an urban Boston primary care setting.

Background: A key strategy to combat the public health crisis of antimicrobial resistance is to use appropriate antibiotics, which is difficult in patients with a penicillin allergy label. Objective: Our aim was to investigate racial and ethnic differences related to penicillin allergy labeling and referral to allergy/immunology in primary care. Methods: This was a retrospective study of Tufts Medical Center's Boston-based primary care patients in 2019. Univariable and multivariable logistic regression models were used to examine demographic associations with (1) penicillin allergy label and (2) allergist referral. Results: Of 21,918 primary care patients, 2,391 (11%) had a penicillin allergy label; of these, 249 (10%) had an allergist referral. In multivariable logistic regression models, older age (adjusted odds ratio [aOR] = 1.06 [95% CI = 1.04-1.09]) and female sex (aOR = 1.58 [95% CI = 1.44-1.74]) were associated with higher odds of penicillin allergy label carriage. Black race (aOR = 0.77 [95% CI = 0.69-0.87]) and Asian race (aOR = 0.47 [95% CI = 0.41-0.53]) were associated with lower odds of penicillin allergy label carriage. In multivariable regression, allergist referral was associated with female sex (aOR = 1.52 [95% CI = 1.10-2.10]) and Black race (aOR = 1.74 [95% CI = 1.25-2.45]). Of 93 patients (37%) who completed their allergy visit, 26 (28%) had received penicillin allergy evaluation or were scheduled to receive a penicillin allergy evaluation at a future visit. Conclusions: There were racial differences in penicillin allergy labeling and referral. Allergy referral for penicillin allergy assessment was rare. Larger studies are needed to assess penicillin allergy labeling and delabeling with an equity focus on optimizing patient health outcomes.

Increased Mortality of Black Incarcerated and Hospitalized People: a Single State Cohort Analysis.

OBJECTIVE: To quantify racial disparities in mortality and post-hospitalization outcomes among incarcerated individuals that were hospitalized during their incarceration period. METHODS: We designed a retrospective cohort study using administrative and hospital data collected from a preferred healthcare referral center for all Massachusetts jails and prisons between January 2011 and December 2018 with linkage to Massachusetts Vital Records and Statistics. We identified 4260 incarcerated individuals with complete data on race/ethnicity that were hospitalized during the study period. The primary study indicators were age, race, ethnicity, length of hospital stay, Elixhauser comorbidity score, incarceration facility type, and number of hospital admissions. The primary outcome was time to death. RESULTS: Of the incarcerated individuals that were hospitalized, 2606 identified as White, 1214 identified as Black, and 411 people who identified as some other race. The hazard of death significantly increased by 3% (OR: 1.03; 95% CI: 1.02-1.03) for each additional yearly increase in age. After adjusting for the interaction between race and age, Black race was significantly associated with 3.01 increased hazard (95% CI: 1.75-5.19) of death for individuals hospitalized while incarcerated compared to White individuals hospitalized while incarcerated. Hispanic ethnicity and being incarcerated in a prison facility was not associated with time to mortality, while increased mean Elixhauser score (HR: 1.07; 95% CI: 1.06-1.08) and ≥ 3 hospital admissions (HR: 2.47; 95% CI: 2.07-2.95) increased the hazard of death. CONCLUSIONS: Our findings suggest disparities exist in the mortality outcomes among Black and White individuals who are hospitalized during incarceration, with an increased rate of death among Black individuals. Despite hypothesized equal access to healthcare within correctional facilities, our findings suggest that incarcerated and hospitalized Black individuals may experience worse disparities than their White counterparts, which has not been previously explored or reported in the literature. In addition to decarceration, advocacy, and political efforts, increased efforts to support research access to datasets of healthcare outcomes, including hospitalization and death, for incarcerated people should be encouraged. Further research is needed to identify and address the implicit and explicit sources of these racial health disparities across the spectrum of healthcare provision.

Racial Differences in Self-Report of Mental Illness and Mental Illness Treatment in the Community: An Analysis of Jail Intake Data.

Jails and prisons in the United States house people with elevated rates of mental health and substance use disorders. The goal of this cross-sectional study was to evaluate the frequency of racial/ethnic differences in the self-report of mental illness and psychiatric medication use at jail entry. Our sample included individuals who had been incarcerated between 2016 and 2020 at the Middlesex Jail & House of Correction, located in Billerica, MA. We used data from the "Offender Management System," the administrative database used by the jail containing data on people who are incarcerated, and COREMR, the electronic medical record (EMR) used in the Middlesex Jail & House of Correction. We evaluated two primary outcomes (1) self-reported mental illness history and (2) self-reported use of psychiatric medication, with the primary indicator of interest as race/ethnicity. At intake, over half (57%) of the sample self-reported history of mental illness and 20% reported the use of psychiatric medications. Among people who self-reported a history of mental illness, Hispanic (AOR: 0.73, 95% CI: 0.60-0.90), Black (AOR: 0.52, 95% CI: 0.43-0.64), Asian/Pacific Islander (Non-Hispanic) people (AOR: 0.31, 95% CI: 0.13-0.74), and people from other racial/ethnic groups (AOR: 0.33, 95% CI: 0.11-0.93) all had decreased odds of reporting psychiatric medications. Mental illness was reported in about one-half of people who entered jail, but only 20% reported receiving medications in the community prior to incarceration. Our findings build on the existing literature on jail-based mental illness and show racial disparities in self-report of psychiatric medications in people who self-reported mental illness. The timing, frequency, and equity of mental health services in both the community and the jail setting deserves further research, investment, and improvement.

Establishing a baseline of antibiotic use in Massachusetts jails reveals heterogeneity in quantity of prescriptions and duration of therapy.

Optimizing antibiotic prescribing is a crucial element of the fight against antibiotic resistance. Antibiotic prescribing patterns in jails have not been studied. We established a baseline of antibiotic prescribing between Massachusetts jails. We detected heterogeneity in quantity and duration of antibiotic prescriptions, revealing an opportunity for improved practice.

Coping with COVID in corrections: a qualitative study among the recently incarcerated on infection control and the acceptability of wastewater-based surveillance.

BACKGROUND: Correctional settings are hotspots for SARS-CoV-2 transmission. Social and biological risk factors contribute to higher rates of COVID-19 morbidity and mortality among justice-involved individuals. Rapidly identifying new cases in congregate settings is essential to promote proper isolation and quarantine. We sought perspectives of individuals incarcerated during COVID-19 on how to improve carceral infection control and their perspectives on acceptability of wastewater-based surveillance (WBS) accompanying individual testing. METHODS: We conducted semi-structured interviews with 20 adults who self-reported being incarcerated throughout the United States between March 2020 and May 2021. We asked participants about facility enforcement of the Centers for Disease Control and Prevention (CDC) COVID-19 guidelines, and acceptability of integrating WBS into SARS-CoV-2 monitoring strategies at their most recent facility. We used descriptive statistics to characterize the study sample and report on acceptability of WBS. We analyzed qualitative data thematically using an iterative process. RESULTS: Participants were predominantly Black or multiple races (50%) and men (75%); 46 years old on average. Most received a mask during their most recent incarceration (90%), although only 40% received counseling on proper mask wearing. A quarter of participants were tested for SARS-CoV-2 at intake. Most (70%) believed they were exposed to the virus while incarcerated. Reoccurring themes included (1) Correctional facility environment leading to a sense of insecurity, (2) Perceptions that punitive conditions in correctional settings were exacerbated by the pandemic; (3) Importance of peers as a source of information about mitigation measures; (4) Perceptions that the safety of correctional environments differed from that of the community during the pandemic; and (5) WBS as a logical strategy, with most (68%) believing WBS would work in the last correctional facility they were in, and 79% preferred monitoring SARS-CoV-2 levels through WBS rather than relying on just individual testing. CONCLUSION: Participants supported routine WBS to monitor for SARS-CoV-2. Integrating WBS into existing surveillance strategies at correctional facilities may minimize the impact of future COVID-19 outbreaks while conserving already constrained resources. To enhance the perception and reality that correctional systems are maximizing mitigation, future measures might include focusing on closer adherence to CDC recommendations and clarity about disease pathogenesis with residents.

Sources of exposure and risk among employees infected with severe acute respiratory coronavirus virus 2 (SARS-CoV-2) in a large, urban, tertiary-care hospital in the United States.

Objective: Hospital employees are at risk of SARS-CoV-2 infection through transmission in 3 settings: (1) the community, (2) within the hospital from patient care, and (3) within the hospital from other employees. We evaluated probable sources of infection among hospital employees based on reported exposures before infection. Design: A structured survey was distributed to participants to evaluate presumed COVID-19 exposures (ie, close contacts with people with known or probable COVID-19) and mask usage. Participants were stratified into high, medium, low, and unknown risk categories based on exposure characteristics and personal protective equipment. Setting: Tertiary-care hospital in Boston, Massachusetts. Participants: Hospital employees with a positive SARS-CoV-2 PCR test result between March 2020 and January 2021. During this period, 573 employees tested positive, of whom 187 (31.5%) participated. Results: We did not detect a statistically significant difference in the proportion of employees who reported any exposure (ie, close contacts at any risk level) in the community compared with any exposure in the hospital, from either patients or employees. In total, 131 participants (70.0%) reported no known high-risk exposure (ie, unmasked close contacts) in any setting. Among those who could identify a high-risk exposure, employees were more likely to have had a high-risk exposure in the community than in both hospital settings combined (odds ratio, 1.89; P = .03). Conclusions: Hospital employees experienced exposure risks in both community and hospital settings. Most employees were unable to identify high-risk exposures prior to infection. When respondents identified high-risk exposures, they were more likely to have occurred in the community.

Corrections Officers' and Sheriffs' Perceptions of COVID-19 Vaccine Operationalization.

Justice-involved populations are at an elevated risk for infectious disease transmission and have been profoundly negatively impacted by the COVID-19 pandemic. Vaccination is being utilized as a primary tool for prevention and protection from serious infection in carceral settings. We examined the barriers and facilitators to vaccine distribution by surveying key stakeholders-sheriffs and corrections officers-in these settings. Most respondents felt prepared for rollout, although they still identified significant barriers to operationalization of vaccine distribution. Barriers ranked highest by stakeholders were vaccine hesitancy and problems related to deficits in communication and planning. There is enormous opportunity to install practices that will address the significant barriers being faced to efficient vaccine distribution and amplify existing facilitators. These could include, for example, the incorporation of in-person community communication models for discussion of the vaccine (and hesitancy) in carceral facilities.

Stakeholder-engaged research is necessary across the criminal-legal spectrum.

People with lived experience of incarceration have higher rates of morbidity and mortality compared to people without history of incarceration. Research conducted unethically in prisons and jails led to increased scrutiny of research to ensure the needs of those studied are protected. One consequence of increased restrictions on research with criminal-legal involved populations is reluctance to engage in research evaluations of healthcare for people who are incarcerated and people who have lived experience of incarceration. Ethical research can be done in partnership with people with lived experience of incarceration and other key stakeholders and should be encouraged. In this article, we describe how stakeholder engagement can be accomplished in this setting, and further, how such engagement leads to impactful research that can be disseminated and implemented across disciplines and communities. The goal is to build trust across the spectrum of people who work, live in, or are impacted by the criminal-legal system, with the purpose of moving toward health equity.

Surgeons' Perspectives on Valve Surgery in People With Drug Use-Associated Infective Endocarditis.

BACKGROUND: Hospitalizations for drug-use associated infective endocarditis (DUA-IE) have led to increasing surgical consultation for valve replacement. Cardiothoracic surgeons' perspectives about the process of decision making around operation for people with DUA-IE are largely unknown. METHODS: This multisite semiqualitative study sought to gather the perspectives of cardiothoracic surgeons on initial and repeat valve surgery for people with DUA-IE through purposeful sampling of surgeons at 7 hospitals: University of Alabama, Tufts Medical Center, Boston Medical Center, Massachusetts General Hospital, University of North Carolina-Chapel Hill, Vanderbilt University Medical Center, and Rhode Island Hospital-Brown University. RESULTS: Nineteen cardiothoracic surgeons (53% acceptance) were interviewed. Perceptions of the drivers of addiction varied as well as approaches to repeat valve operations. There were mixed views on multidisciplinary meetings, although many surgeons expressed an interest in more efficient meetings and more intensive postoperative and posthospitalization multidisciplinary care. CONCLUSIONS: Cardiothoracic surgeons are emotionally and professionally impacted by making decisions about whether to perform valve operation for people with DUA-IE. The use of efficient, agenda-based multidisciplinary care teams is an actionable solution to improve cross-disciplinary partnerships and outcomes for people with DUA-IE.

Barriers to severe acute respiratory coronavirus virus 2 (SARS-CoV-2) testing reported by healthcare workers during the first pandemic wave at an academic center in Boston, Massachusetts.

Healthcare workers (HCWs) experience barriers to severe acute respiratory coronavirus virus 2 (SARS-CoV-2) testing specific to their perceptions of access, and employment factors. A survey was sent to all employees at one Boston hospital to examine their perceived barriers to testing. HCWs who reported difficulty paying their bills were less likely to receive a SARS-CoV-2 test.