The role of stroke care infrastructure on the effectiveness of a hub-and-spoke telestroke model in South Carolina.

OBJECTIVE: To examine the relationship between stroke care infrastructure and stroke quality-of-care outcomes at 29 spoke hospitals participating in the Medical University of South Carolina (MUSC) hub-and-spoke telestroke network. MATERIALS AND METHODS: Encounter-level data from MUSC's telestroke patient registry were filtered to include encounters during 2015-2022 for patients aged 18 and above with a clinical diagnosis of acute ischemic stroke, and who received intravenous tissue plasminogen activator. Unadjusted and adjusted generalized estimating equations assessed associations between time-related stroke quality-of-care metrics captured during the encounter and the existence of the two components of stroke care infrastructure-stroke coordinators and stroke center certifications-across all hospitals and within hospital subgroups defined by size and rurality. RESULTS: Telestroke encounters at spoke hospitals with stroke coordinators and stroke center certifications were associated with shorter door-to-needle (DTN) times (60.9 min for hospitals with both components and 57.3 min for hospitals with one, vs. 81.2 min for hospitals with neither component, p <.001). Similar patterns were observed for the percentage of encounters with DTN time of ≤60 min (63.8% and 68.9% vs. 32.0%, p <.001) and ≤45 min (34.0% and 38.4% vs. 8.42%, p <.001). Associations were similar for other metrics (e.g., door-to-registration time), and were stronger for smaller (vs. larger) hospitals and rural (vs. urban) hospitals. CONCLUSIONS: Stroke coordinators or stroke center certifications may be important for stroke quality of care, especially at spoke hospitals with limited resources or in rural areas.

A Mixed-Methods Approach for Evaluating Implementation Processes and Program Costs for a Hypertension Management Program Implemented in a Federally Qualified Health Center.

Team-based care approaches are effective at improving hypertension control and have been used in clinical practice to improve hypertension outcomes. This study implemented and evaluated the Hypertension Management Program (HMP), which was originally developed in a high-resource health setting, in a health system with fewer resources and a patient population disproportionately affected by hypertension. Our objectives were to describe how a health system could adapt HMP to meet their needs and calculate total program costs. HMP uses a team-based, patient-centered approach involving clinical pharmacists who contribute to managing patients who have hypertension and ultimately preventing premature death due to uncontrolled hypertension. HMP has 10 components (e.g., EHR patient registries and outreach lists, no copayment walk-in blood pressure checks). Our project involved implementing the key components of HMP in a federally qualified health center (FQHC) in South Carolina. Adaptations from the key components of HMP were made to fit the participants' settings. A mixed-methods evaluation assessed implementation processes, program costs, and implementation facilitators and barriers. From September 2018 to December 2019, clinical pharmacists conducted 758 hypertension management visits (HMVs) with 316 patients with hypertension. Total program costs for HMP were $325,532 overall and $16,277 per month. Monthly cost per patient was $3.62. The high engagement among clinical pharmacists, along with provider engagements, followed up by the subsequent referral of patients to HMP, facilitated the implementation process. Staff members observed improvements in hypertension control, which increased participation buy-in. Barriers included staff turnover, the perception among some providers that HMP took too much time, as well as perception of HMP as a pharmacy-specific initiative. A team-based, patient-centered approach to hypertension management can be adapted for FQHCs or similar settings that serve patient populations disproportionately affected by hypertension.

Promoting corporate image or preventing underage use? Analysis of the advertising strategy and expenditures of the JUUL parent education for youth vaping prevention campaign.

OBJECTIVE: In April 2018, JUUL Labs announced a $30 million investment in efforts to combat underage use of its products through 'independent research, youth and parent education and community engagement'. Prior evidence demonstrates that tobacco industry-funded prevention programmes are ineffective and may work against tobacco control efforts; they do not discourage novices and youth from tobacco use but often improve the tobacco industry's public image. We describe the nature, timing of and expenditures related to the JUUL underage use prevention advertisements across media channels. METHODS: Expenditures for newspaper, magazine, television, and radio marketing and promotional efforts were collected through Kantar Media's 'Stradegy' dashboard, an online platform which provides counts of advertisement occurrences and expenditures on various media channels. JUUL public relations and corporate social responsibility ads were identified in the Kantar Database. All ad expenditures were extracted and aggregated by date. Analysis of the expenditure data was triangulated with newspaper and industry advertisement archives. RESULTS: Advertisements aired nationally and in over half of all US-designated market areas (n=130) across media platforms including newspapers, magazines, radio, and online in mobile web and internet displays. In 2018, JUUL Labs spent $30 million, predominantly for print advertising. The 'What Parents Need to Know about JUUL' ads primarily advertised JUUL's smoking reduction 'mission' and promoted the product. By 2019, advertising increased to $36.2 million. JUUL's message strategy transitioned to 'Cracking Down on Underage Sales in Retail Stores' and featured adult smoker testimonies, linking JUUL to smoking cessation. DISCUSSION: Marketing expenditures promoting JUUL's corporate social responsibility mission exceeded their $30 million investment in the underage use prevention efforts. The expenditures were focused on the media market areas where health organisation and legislative officials were launching investigations into JUUL social media and other promotional strategies.

Initiatives to Reduce Maternal Mortality and Severe Maternal Morbidity in the United States : A Narrative Review.

Maternal mortality and severe maternal morbidity are critical health issues in the United States, with unacceptably high rates and racial, ethnic, and geographic disparities. Various factors contribute to these adverse maternal health outcomes, ranging from patient-level to health system-level factors. Furthermore, a majority of pregnancy-related deaths are preventable. This review briefly describes the epidemiology of maternal mortality and severe maternal morbidity in the United States and discusses selected initiatives to reduce maternal mortality and severe maternal morbidity in the areas of data and surveillance; clinical workforce training and patient education; telehealth; comprehensive models and strategies; and clinical guidelines, protocols, and bundles. Related Health Resources and Services Administration initiatives are also described.

The inconvincible patient: how clinicians perceive demand for antibiotics in the outpatient setting.

BACKGROUND: Perceived patient demand for antibiotics drives unnecessary antibiotic prescribing in outpatient settings, but little is known about how clinicians experience this demand or how this perceived demand shapes their decision-making. OBJECTIVE: To identify how clinicians perceive patient demand for antibiotics and the way these perceptions stimulate unnecessary prescribing. METHODS: Qualitative study using semi-structured interviews with clinicians in outpatient settings who prescribe antibiotics. Interviews were analyzed using conventional and directed content analysis. RESULTS: Interviews were conducted with 25 clinicians from nine practices across three states. Patient demand was the most common reason respondents provided for why they prescribed non-indicated antibiotics. Three related factors motivated clinically unnecessary antibiotic use in the face of perceived patient demand: (i) clinicians want their patients to regard clinical visits as valuable and believe that an antibiotic prescription demonstrates value; (ii) clinicians want to avoid negative repercussions of denying antibiotics, including reduced income, damage to their reputation, emotional exhaustion, and degraded relationships with patients; (iii) clinicians believed that certain patients are impossible to satisfy without an antibiotic prescription and felt that efforts to refuse antibiotics to such patients wastes time and invites the aforementioned negative repercussions. Clinicians in urgent care settings were especially likely to describe being motivated by these factors. CONCLUSION: Interventions to improve antibiotic use in the outpatient setting must address clinicians' concerns about providing value for their patients, fear of negative repercussions from denying antibiotics, and the approach to inconvincible patients.

Prevalence of unrepaired third- and fourth-degree tears among women taken to the operating room for repair of presumed obstetric fistula during two fistula camps in Kenya.

INTRODUCTION AND HYPOTHESIS: More than 2 million women on earth today are said to be suffering from obstetric fistula (OF), a communication between the vagina and either the urinary tract or rectum. Since unrepaired third- and fourth-degree perineal tears often manifest with symptoms identical to OF, we hypothesized that the global burden of OF is in part due to these unrepaired deep obstetric tears. METHODS: Four consultant gynecologists retrospectively reviewed the medical and operative records of all obstetric fistula cases that underwent surgical repair during the July and August, 2014, Kenyatta National Hospital and Embu Provincial Hospital Fistula Camps in Kenya. RESULTS: One hundred and eighty charts were reviewed. All 180 women had fecal incontinence (FI), urinary incontinence (UI), or both as their primary complaint. Sixty of the 180 (33 %) women had isolated FI as their presenting symptom, and at operation, 57 of these 60 (95 %) were found to have unrepaired third- and fourth-degree obstetric tears. Ninety-two of the 180 (51 %) women with OF symptoms ultimately had true OF confirmed at operation. CONCLUSION: These findings suggest that many women with OF symptoms in Kenya may harbor unrepaired third- and fourth-degree tears. Additionally, women with isolated FI may be more likely to suffer from third- and fourth-degree tears than from true OF. Immediate postpartum diagnosis and repair of third- and fourth-degree perineal tears could significantly reduce the overall burden of women with symptoms of OF.

Use of prophylactic uterotonics during the third stage of labor: a survey of provider practices in community health facilities in Sierra Leone.

BACKGROUND: Postpartum hemorrhage remains the leading cause of maternal mortality worldwide. Administration of uterotonics during the third stage of labor is a simple and well established intervention that can significantly decrease the development of postpartum hemorrhage. Little is known about the use of prophylactic uterotonics in peripheral health centers, where the majority of normal deliveries occur. The purpose of this study is to assess health provider current practices and determinants to the use of prophylactic uterotonics in Sierra Leone, a country with one of the highest maternal mortality ratios worldwide. METHODS: This is a mixed methods study using descriptive cross-sectional survey and qualitative interviews in community health facilities in Freetown, Sierra Leone following a comprehensive training on postpartum hemorrhage. Facilities and providers were surveyed between May and June 2014. Qualitative methods were used to identify barriers and facilitators to the use of prophylactic uterotonics. RESULTS: A total of 134 providers were surveyed at 39 periphreal health facilities. Thirteen facilities (39 %) reported an inconsistent supply of oxytocin. The majority of facilities (64 %) stored oxytocin at room temperature. Provider level, in-service training, and leadership role were significantly associated with prophylactic uterotonic use. Overall, 62 % of providers reported routine use. Midwives were most likely to routinely administer uterotonics (93 %), followed by community health officers/assistants (78 %), maternal and child health aides (56 %), and state-enrolled community health nurses (52 %). Of the providers who received in-service training, 67 % reported routine use; of those with no in-service training, 42 % reported routine use. Qualitative analysis revealed that facility protocols, widespread availability, and provider perception of utility facilitated routine use. Common barriers reported included inconsistent supply of uterotonics, lack of knowledge regarding timely administration, and provider attitude regarding utility of uterotonics following normal deliveries. CONCLUSION: There is considerable room for improvement in availability and administration of prophylactic uterotonics. Understanding barriers to routine use may aid in developing multifaceted pre-service and in-service training interventions designed to improve routine intrapartum care.

A Safe-Anesthesia Innovation for Emergency and Life-Improving Surgeries When no Anesthetist is Available: A Descriptive Review of 193 Consecutive Surgeries.

BACKGROUND: The worldwide human resource gap in anesthesia services often presents a barrier to accessing life-saving and life-improving surgeries. This paper assessed the impact of a ketamine anesthesia package, Every Second Matters-Ketamine (ESM-Ketamine)™, for use in emergency and life-improving surgeries by non-anesthetist clinicians in a resource-limited setting when no anesthetist was available. METHODS: We analyzed prospectively collected data from 193 surgeries constituting a pilot implementation of the ESM-Ketamine package, among three sub-district hospitals in Western Kenya. The study population comprises patients who required emergency or life-improving surgery when no anesthetist was available. Non-anesthetist clinicians in three sub-district hospitals underwent a 5-day training course in ESM-Ketamine complemented by checklists and an ESM-Ketamine Kit. Data were collected prospectively every time the ESM-Ketamine pathway was invoked. The training cases, although primarily tubal ligations, were included. The primary outcome measures centered on capturing the ability to safely support emergency and life-improving surgeries, when no anesthetist was available, through invoking the ESM-Ketamine pathway. The registry was critically examined using standard descriptive and frequency analysis. RESULTS: 193 surgical procedures were supported using the ESM-Ketamine package by five ESM-Ketamine trained providers. Brief (<30 s) patient desaturation below 92% and hallucinations occurred in 16 out of 186 (8.6%) and 23 out of 190 patients (12.1%), respectively. There were no reported major adverse events such as death, prolonged desaturations (over 30 s), or injury resulting from ketamine use. CONCLUSION: This study provides promising initial evidence that the ESM-Ketamine package can support emergency and life-improving surgeries in resource-limited settings when no anesthetist is available.

Emergency care and referral among isolated island populations in the Bahamas.

BACKGROUND: Isolated island populations face unique health challenges. In the Bahamas, the islands of Mayaguana, Inagua, Crooked Island, Acklins, and Long Cay-referred to as the MICAL Constituency-are among the most isolated. OBJECTIVES: Our objective was to better understand regional emergency care needs and capabilities, and determine how emergency care can be optimized among island populations. METHODS: During the summer of 2013, the project team conducted semi-structured key-informant interviews and small-group discussions among all health care teams in the MICAL region, as well as a community-based household survey on the island of Mayaguana. The interviews and small-group discussions consisted of open-response questions related to health care services, equipment, supplies, medications, and human resources. The community-based survey examined the prevalence of chronic noncommunicable diseases (CNCDs) and associated risk factors affecting the inhabitants of the region. RESULTS: The average number of annual emergency referrals from each of the MICAL islands was approximately 25-30, and reasons for referrals off-island included chest pain, abdominal pain, trauma, and dysfunctional uterine bleeding. Traditional prehospital care is not established in the MICAL Constituency. Providers reported feelings of isolation from the distant health system in Nassau. Whereas most clinics have a well-stocked pharmacy of oral medications, diagnostic capabilities are limited. The household survey showed a high prevalence of CNCDs and associated risk factors. CONCLUSION: Ongoing in-service emergency care training among MICAL providers is needed. Additional equipment could significantly improve emergency care capabilities, specifically, equipment to manage chest pain, fractures, and other trauma. Community-based preventive services and education could improve the overall health of the island populations.

Innovating for the developing world: meeting the affordability challenge.

OBJECTIVE: Ultrasound technologies have gained increasing prominence and accessibility in the developing world as manufacturers focus on this region as an emerging market. More extensive ultrasound use holds promise for addressing the disproportionate morbidity and mortality that continues to plague the developing world, particularly in the area of obstetrics. CONCLUSION: In this article, we describe the challenge of making ultrasound technologies affordable to health care providers in resource-limited regions vis-à-vis an innovative group of midwives in Nairobi.

Lessons Learned from a National Hospital Antibiotic Stewardship Implementation Project.

BACKGROUND: The goal of antibiotic stewardship programs (ASPs) is to ensure that patients receive effective therapy while minimizing adverse events. To overcome barriers commonly faced in implementing successful ASPs, the Agency for Healthcare Research and Quality (AHRQ) established a multifaceted, nationwide Safety Program for Improving Antibiotic Use in 2018. This report summarizes the lessons learned from the implementation of this initiative based on structured interviews of personnel from participating sites. METHODS: At the completion of the one-year initiative, semistructured exit interviews were conducted with site leaders at 151 of the 402 hospitals that participated. These interviews consisted of open-ended questions about the perceived effectiveness of components of the Safety Program. Qualitative analyses incorporated both deductive coding themes (based on existing literature) and an iteratively developed inductive coding framework (based on salient themes that emerged from a subset of interviews). RESULTS: Several components of the Safety Program were identified as effective in expanding local stewardship activities, including techniques and strategies to implement sustainable ASPs, access to Implementation Advisors to keep sites engaged, provision of local benchmarked antibiotic use data to compare to similar hospitals, and Safety Program materials such as the antibiotic time-out tool to integrate stewardship techniques into daily work flows. The biggest challenges to greater effectiveness were suboptimal frontline staff engagement and difficulty changing antibiotic prescribing culture. Some approaches used to overcome these barriers (peer-to-peer communication and education through team huddles, identifying physician champions, informal rounds to enhance collegiality and buy-in, and engagement of hospital leadership) were identified. CONCLUSION: Lessons learned from the Safety Program can be applied by other teams looking to promote an effective ASP at their hospital or system. The themes that emerged in this study likely also have relevance across a wide range of large-scale quality improvement initiatives.

The women's health needs study among women from countries with high prevalence of female genital mutilation living in the United States: Design, methods, and participant characteristics.

BACKGROUND: The Women's Health Needs Study (WHNS) collected information on the health characteristics, needs, and experiences, including female genital mutilation (FGM) experiences, attitudes, and beliefs, of women aged 18 to 49 years who were born, or whose mothers were born, in a country where FGM is prevalent living in the US. The purpose of this paper is to describe the WHNS design, methods, strengths and limitations, as well as select demographic and health-related characteristics of participants. METHODS: We conducted a cross-sectional survey from November 2020 -June 2021 in four US metropolitan areas, using a hybrid venue-based sampling (VBS) and respondent-driven sampling (RDS) approach to identify women for recruitment. RESULTS: Of 1,132 participants, 395 were recruited via VBS and 737 RDS. Most were born, or their mothers were born, in either a West African country (Burkina Faso, Guinea, Mali, Mauritania, Sierra Leone, The Gambia) (39.0%) or Ethiopia (30.7%). More than a third were aged 30-39 years (37.5%) with a majority who immigrated at ages ≥13 years (86.6%) and had lived in the United States for ≥5 years (68.9%). Medicaid was the top health insurer (52.5%), followed by private health insurance (30.5%); 17% of participants had no insurance. Nearly half of women reported 1-2 healthcare visits within the past 12 months (47.7%). One in seven did not get needed health care due to cost (14.8%). Over half have ever used contraception (52.1%) to delay or avoid pregnancy and 76.9% had their last pelvic and/or Papanicolaou (pap) exam within the past 3 years. More than half experienced FGM (55.0%). Nearly all women believed that FGM should be stopped (92.0%). CONCLUSION: The VBS/RDS approach enabled recruitment of a diverse study population. WHNS advances research related to the health characteristics, needs, and experiences of women living in the US from countries where FGM is prevalent.

An international comparative public health analysis of sex trafficking of women and girls in eight cities: achieving a more effective health sector response.

Sex trafficking, trafficking for the purpose of forced sexual exploitation, is a widespread form of human trafficking that occurs in all regions of the world, affects mostly women and girls, and has far-reaching health implications. Studies suggest that up to 50 % of sex trafficking victims in the USA seek medical attention while in their trafficking situation, yet it is unclear how the healthcare system responds to the needs of victims of sex trafficking. To understand the intersection of sex trafficking and public health, we performed in-depth qualitative interviews among 277 antitrafficking stakeholders across eight metropolitan areas in five countries to examine the local context of sex trafficking. We sought to gain a new perspective on this form of gender-based violence from those who have a unique vantage point and intimate knowledge of push-and-pull factors, victim health needs, current available resources and practices in the health system, and barriers to care. Through comparative analysis across these contexts, we found that multiple sociocultural and economic factors facilitate sex trafficking, including child sexual abuse, the objectification of women and girls, and lack of income. Although there are numerous physical and psychological health problems associated with sex trafficking, health services for victims are patchy and poorly coordinated, particularly in the realm of mental health. Various factors function as barriers to a greater health response, including low awareness of sex trafficking and attitudinal biases among health workers. A more comprehensive and coordinated health system response to sex trafficking may help alleviate its devastating effects on vulnerable women and girls. There are numerous opportunities for local health systems to engage in antitrafficking efforts while partnering across sectors with relevant stakeholders.

The CDC Foundation's COVID-19 emergency response pilot project: a case study in knowledge brokering for older adults and caregivers.

OBJECTIVE: The coronavirus disease 2019 (COVID-19) public health emergency has disproportionately affected older adults and their caregivers, requiring evidence-based and coordinated efforts to meet their health and social needs. This paper describes the role of the CDC Foundation as a knowledge broker working with public health partners to rapidly meet the unmet health, social, and other needs of older adults and caregivers during the COVID-19 pandemic. Type of program or service: Qualitative case study using the Role Model for Knowledge Brokering framework to describe a project that translated public health research into practice during the COVID-19 pandemic response. METHODS: This case study documents the experiences of a US-based foundation serving as a knowledge broker, carrying out three roles: establishing research partnerships to study unmet health, social, and other needs of older adults and caregivers during COVID-19; coordinating with partners to identify evidence-based strategies; and rapidly implementing four emergency response pilot projects. RESULTS: The emergency response pilot projects created included: an online resource library - -SearchFindHelp.org - of public health programs and resources for organisations serving older adults and caregivers; digital literacy training for older adults and caregivers; multicultural caregiver tools to serve rural and Asian American and Pacific Islander older adults; and a grant program to expand local, direct services for older adults. SearchFindHelp.org had 46 781 new users and 101 908 total views from June 2021-March 2023. Older adults and caregivers who participated in digital literacy training from May-September 2021 were more likely to find health resources online and schedule and attend an online doctor's visit. A paid media campaign in December 2021 was launched to raise awareness of multicultural caregiver tools. Ten community organisations expanded direct, local services for older adults. LESSONS LEARNT: This project highlights the valuable role a foundation can play as a knowledge broker in rapidly translating research into practice during a public health emergency response, to address emerging community needs.

Effectiveness evaluation of a hypertension management program in a Federally Qualified Health Center (FQHC).

The objective of this study was to examine effectiveness of a Hypertension Management Program (HMP) in a Federally Qualified Health Center (FQHC). From September 2018 through December 2019, we implemented HMP in seven clinics of an FQHC in rural South Carolina. A pre/post evaluation design estimated the association of HMP with hypertension control rates and systolic blood pressure using electronic health record data among 3,941 patients. A chi-square test estimated change in mean control rates in pre- and intervention periods. A multilevel multivariable logistic regression model estimated the incremental impact of HMP on odds of hypertension control. Results showed that 53.4% of patients had controlled hypertension pre-intervention (September 2016-September 2018); 57.3% had controlled hypertension at the end of the observed implementation period (September 2018-December 2019) (p < 0.01). Statistically significant increases in hypertension control rates were observed in six of seven clinics (p < 0.05). Odds of controlled hypertension were 1.21 times higher during the intervention period compared to pre-intervention (p < 0.0001). Findings can inform the replication of HMP in FQHCs and similar health care settings, which play a pivotal role in caring for patients with health and socioeconomic disparities.

Telehealth Use to Address Cardiovascular Disease and Hypertension in the United States: A Systematic Review and Meta-Analysis, 2011-2021.

Background: The use of telehealth for the management and treatment of hypertension and cardiovascular disease (CVD) has increased across the United States (U.S.), especially during the COVID-19 pandemic. Telehealth has the potential to reduce barriers to accessing health care and improve clinical outcomes. However, implementation, outcomes, and health equity implications related to these strategies are not well understood. The purpose of this review was to identify how telehealth is being used by U.S. health care professionals and health systems to manage hypertension and CVD and to describe the impact these telehealth strategies have on hypertension and CVD outcomes, with a special focus on social determinants of health and health disparities. Methods: This study comprised a narrative review of the literature and meta-analyses. The meta-analyses included articles with intervention and control groups to examine the impact of telehealth interventions on changes to select patient outcomes, including systolic and diastolic blood pressure. A total of 38 U.S.-based interventions were included in the narrative review, with 14 yielding data eligible for the meta-analyses. Results: The telehealth interventions reviewed were used to treat patients with hypertension, heart failure, and stroke, with most interventions employing a team-based care approach. These interventions utilized the expertise of physicians, nurses, pharmacists, and other health care professionals to collaborate on patient decisions and provide direct care. Among the 38 interventions reviewed, 26 interventions utilized remote patient monitoring (RPM) devices mostly for blood pressure monitoring. Half the interventions used a combination of strategies (e.g., videoconferencing and RPM). Patients using telehealth saw significant improvements in clinical outcomes such as blood pressure control, which were comparable to patients receiving in-person care. In contrast, the outcomes related to hospitalizations were mixed. There were also significant decreases in all-cause mortality when compared to usual care. No study explicitly focused on addressing social determinants of health or health disparities through telehealth for hypertension or CVD. Conclusions: Telehealth appears to be comparable to traditional in-person care for managing blood pressure and CVD and may be seen as a complement to existing care options for some patients. Telehealth can also support team-based care delivery and may benefit patients and health care professionals by increasing opportunities for communication, engagement, and monitoring outside a clinical setting.

Assessment of Changes in Visits and Antibiotic Prescribing During the Agency for Healthcare Research and Quality Safety Program for Improving Antibiotic Use and the COVID-19 Pandemic.

Importance: The Agency for Healthcare Research and Quality (AHRQ) Safety Program for Improving Antibiotic Use aimed to improve antibiotic prescribing in ambulatory care practices by engaging clinicians and staff to incorporate antibiotic stewardship into practice culture, communication, and decision-making. Little is known about implementation of antibiotic stewardship in ambulatory care practices. Objective: To examine changes in visits and antibiotic prescribing during the AHRQ Safety Program. Design, Setting, and Participants: This cohort study evaluated a quality improvement intervention in ambulatory care throughout the US in 389 ambulatory care practices from December 1, 2019, to November 30, 2020. Exposures: The AHRQ Safety Program used webinars, audio presentations, educational tools, and office hours to engage stewardship leaders and clinical staff to address attitudes and cultures that challenge judicious antibiotic prescribing and incorporate best practices for the management of common infections. Main Outcomes and Measures: The primary outcome of the Safety Program was antibiotic prescriptions per 100 acute respiratory infection (ARI) visits. Data on total visits and ARI visits were also collected. The number of visits and prescribing rates from baseline (September 1, 2019) to completion of the program (November 30, 2020) were compared. Results: Of 467 practices enrolled, 389 (83%) completed the Safety Program; of these, 292 (75%) submitted complete data with 6 590 485 visits to 5483 clinicians. Participants included 82 (28%) primary care practices, 103 (35%) urgent care practices, 34 (12%) federally supported practices, 39 (13%) pediatric urgent care practices, 21 (7%) pediatric-only practices, and 14 (5%) other practice types. Visits per practice per month decreased from a mean of 1624 (95% CI, 1317-1931) at baseline to a nadir of 906 (95% CI, 702-1111) early in the COVID-19 pandemic (April 2020), and were 1797 (95% CI, 1510-2084) at the end of the program. Total antibiotic prescribing decreased from 18.2% of visits at baseline to 9.5% at completion of the program (-8.7%; 95% CI, -9.9% to -7.6%). Acute respiratory infection visits per practice per month decreased from baseline (n = 321) to a nadir of 76 early in the pandemic (May 2020) and gradually increased through completion of the program (n = 239). Antibiotic prescribing for ARIs decreased from 39.2% at baseline to 24.7% at completion of the program (-14.5%; 95% CI, -16.8% to -12.2%). Conclusions and Relevance: In this study of US ambulatory practices that participated in the AHRQ Safety Program, significant reductions in the rates of overall and ARI-related antibiotic prescribing were noted, despite normalization of clinic visits by completion of the program. The forthcoming AHRQ Safety Program content may have utility in ambulatory practices across the US.

Implementation of an Antibiotic Stewardship Program in Long-term Care Facilities Across the US.

IMPORTANCE: Antibiotic overuse in long-term care (LTC) is common, prompting calls for antibiotic stewardship programs (ASPs) designed for specific use in these settings. The optimal approach to establish robust, sustainable ASPs in LTC facilities is unknown. OBJECTIVES: To determine if the Agency for Healthcare Research and Quality (AHRQ) Safety Program for Improving Antibiotic Use, an educational initiative to establish ASPs focusing on patient safety, is associated with reductions in antibiotic use in LTC settings. DESIGN, SETTING, AND PARTICIPANTS: This quality improvement study including 439 LTC facilities in the US assessed antibiotic therapy data following a pragmatic quality-improvement program, which was implemented to assist facilities in establishing ASPs and with antibiotic decision-making. Training was conducted between December 2018 and November 2019. Data were analyzed from January 2019 to December 2019. INTERVENTIONS: Fifteen webinars occurred over 12 months (December 2018 to November 2019), accompanied by additional tools, activities, posters, and pocket cards. All clinical staff were encouraged to participate. MAIN OUTCOMES AND MEASURES: The primary outcome was antibiotic starts per 1000 resident-days. Secondary outcomes included days of antibiotic therapy (DOT) per 1000 resident-days, the number of urine cultures per 1000 resident-days, and Clostridioides difficile laboratory-identified events per 10 000 resident-days. All outcomes compared data from the baseline (January-February 2019) to the completion of the program (November-December 2019). Generalized linear mixed models with random intercepts at the site level assessed changes over time. RESULTS: Of a total 523 eligible LTC facilities, 439 (83.9%) completed the safety program. The mean difference for antibiotic starts from baseline to study completion per 1000 resident-days was -0.41 (95% CI, -0.76 to -0.07; P = .02), with fluoroquinolones showing the greatest decrease at -0.21 starts per 1000 resident-days (95% CI, -0.35 to -0.08; P = .002). The mean difference for antibiotic DOT per 1000 resident-days was not significant (-3.05; 95% CI, -6.34 to 0.23; P = .07). Reductions in antibiotic starts and use were greater in facilities with greater program engagement (as measured by webinar attendance). While antibiotic starts and DOT in these facilities decreased by 1.12 per 1000 resident-days (95% CI, -1.75 to -0.49; P < .001) and 9.97 per 1000 resident-days (95% CI, -15.4 to -4.6; P < .001), respectively, no significant reductions occurred in low engagement facilities. Urine cultures per 1000 resident-days decreased by 0.38 (95% CI, -0.61 to -0.15; P = .001). There was no significant change in facility-onset C difficile laboratory-identified events. CONCLUSIONS AND RELEVANCE: Participation in the AHRQ safety program was associated with the development of ASPs that actively engaged clinical staff in the decision-making processes around antibiotic prescriptions in participating LTC facilities. The reduction in antibiotic DOT and starts, which was more pronounced in more engaged facilities, indicates that implementation of this multifaceted program may support successful ASPs in LTC settings.

Sex and Labor Trafficking in Paraguay: Risk Factors, Needs Assessment, and the Role of the Health Care System.

Trafficking of adults and children for both sex and labor is a human rights violation occurring with alarming frequency throughout the world, and resulting in profound harm to close-knit communities and severe health consequences for victims. Certain areas, such as the country of Paraguay, are at a higher risk for trafficking due to unique economic, cultural, and geographic factors. Thousands of people, especially children, are trafficked within Paraguay's borders, and many eventually are transported to neighboring countries and sometimes to Europe and elsewhere. Using case study methodology and "city" as the unit of study, researchers interviewed 18 key anti-trafficking stakeholders from government and nongovernmental organizations in two major metropolitan centers for trafficking in Paraguay, Asunción, and Encarnación. Through semistructured interviews, this qualitative study examines risk factors for trafficking, health outcomes, interventions needed within the health care sector, and programs needed to combat trafficking. We identified risk factors including poverty, marginalization of indigenous people, gender inequality, domestic servitude of children (criadazgo), and political hesitance to enact protective legislation. Victims of trafficking were reported to suffer from physical injuries, unintended pregnancies, sexually transmitted infections, and mental health issues such as depression and posttraumatic stress disorder. These predispose victims to difficulties reintegrating into their communities and ultimately to retrafficking. A major gap was identified in the lack of sufficient lodging and rehabilitation services for rescued victims, affordable access to trauma-sensitive health care for victims, and scarce mental health services. Many of the findings are applicable across the world and may be of use to guide future anti-trafficking efforts in Paraguay and beyond.