Health Evaluation and Referral Assistant: A Randomized Controlled Trial of a Web-Based Screening, Brief Intervention, and Referral to Treatment System to Reduce Risky Alcohol Use Among Emergency Department Patients

BACKGROUND: Computer technologies hold promise for implementing alcohol screening, brief intervention, and referral to treatment (SBIRT). Questions concerning the most effective and appropriate SBIRT model remain. OBJECTIVE: The aim of this study was to evaluate the impact of a computerized SBIRT system called the Health Evaluation and Referral Assistant (HERA) on risky alcohol use treatment initiation. METHODS: Alcohol users (N=319) presenting to an emergency department (ED) were considered for enrollment. Those enrolled (n=212) were randomly assigned to the HERA, to complete a patient-administered assessment using a tablet computer, or a minimal-treatment control, and were followed for 3 months. Analyses compared alcohol treatment provider contact, treatment initiation, treatment completion, and alcohol use across condition using univariate comparisons, generalized estimating equations (GEEs), and post hoc chi-square analyses. RESULTS: HERA participants (n=212; control=115; intervention=97) did not differ between conditions on initial contact with an alcohol treatment provider, treatment initiation, treatment completion, or change in risky alcohol use behavior. Subanalyses indicated that HERA participants, who accepted a faxed referral, were more likely to initiate contact with a treatment provider and initiate treatment for risky alcohol use, but were not more likely to continue engaging in treatment, or to complete treatment and change risky alcohol use behavior over the 3-month period following the ED visit. CONCLUSIONS: The HERA promoted initial contact with an alcohol treatment provider and initiation of treatment for those who accepted the faxed referral, but it did not lead to reduced risky alcohol use behavior. Factors which may have limited the HERA\u27s impact include lack of support for the intervention by clinical staff, the low intensity of the brief and stand-alone design of the intervention, and barriers related to patient follow-through, (eg, a lack of transportation or childcare, fees for services, or schedule conflicts). TRIAL REGISTRATION: International Standard Randomized Controlled Trial Number (ISRCTN): NCT01153373; https://clinicaltrials.gov/ct2/show/NCT01153373 (Archived by WebCite at http://www.webcitation.org/6pHQEpuIF)

High Risk Human Papillomavirus Persistence Among HIV-infected Young Women in South Africa

SummaryObjectivesPersistence of infection with high-risk Human papillomaviruses (HR-HPV) increases the risk of incident and progressive precancerous lesions of the cervix. Rates of HR-HPV persistence have been shown to be increased among HIV-infected adult women, however there is a paucity of literature addressing HPV persistence in the young HIV-infected population. We compared rates of HR-HPV persistence between HIV-infected and HIV-uninfected young women.MethodsWe obtained self-collected vaginal swabs at six-month intervals from 50 HIV-uninfected and 33 HIV-infected young women recruited through a community youth center (age 17-21 years) and compared rates of HR-HPV persistence. HR-HPV testing was conducted using the Roche's Linear Array® HPV Test.ResultsEighty-three prevalent (upon baseline testing) and incident (upon subsequent testing) individual HR-HPV infections were identified among 43 members of the cohort (23 HIV-uninfected and 20 HIV-infected). At twelve months, 19% of baseline HR-HPV infections continued to be present with a statistically significant difference between HIV-uninfected and HIV-infected participants (4% versus 31%; p=0.01).ConclusionsHIV-infected young women in our cohort had a seven-fold increased rate of persistence of HR-HPV overall at 12 months, indicating an increased risk for incident and progressive precancerous lesions. Identification of persistent infection with HR-HPV may complement cytological findings in determining the need for colposcopy

Motivation rulers for smoking cessation: a prospective observational examination of construct and predictive validity

BACKGROUND: Although popular clinically, the psychometric properties of motivation rulers for tobacco cessation are unknown. This study examined the psychometric properties of rulers assessing importance, readiness, and confidence in tobacco cessation. METHODS: This observational study of current smokers was conducted at 10 US emergency departments (EDs). Subjects were assessed during their ED visit (baseline) and reassessed two weeks later. We examined intercorrelations between the rulers as well as their construct and predictive validity. Hierarchical multinomial logistic regressions were used to examine the rulers\u27 predictive ability after controlling for covariables. RESULTS: We enrolled 375 subjects. The correlations between the three rulers ranged from 0.50 (between Important and Confidence) to 0.70 (between Readiness and Confidence); all were significant (p \u3c 0.001). Individuals in the preparation stage displayed the highest motivation-ruler ratings (all rulers F 2, 363 \u3e/= 43; p \u3c 0.001). After adjusting for covariables, each of the rulers significantly improved prediction of smoking behavior change. The strength of their predictive ability was on par with that of stage of change. CONCLUSION: Our results provide preliminary support for the psychometric soundness of the importance, readiness, and confidence rulers

Cumulative Impact of HIV and Multiple Concurrent Human Papillomavirus Infections on the Risk of Cervical Dysplasia

Infection with HIV is known to increase the risk of cervical cancer. In addition, evidence suggests that concurrent infection with multiple human papillomavirus (HPV) genotypes increases the risk of cervical dysplasia more than infection with a single HPV genotype. However, the impact of the combination of HIV coinfection and presence of multiple concurrent HPV infections on the risk of cervical dysplasia is uncertain. We compared the results of HPV testing and Pap smears between HIV-infected and HIVuninfected young women to assess the cumulative impact of these two conditions. We found that both HIV and the presence of multiple concurrent HPV infections are associated with increased risk of associated Pap smear abnormality and that the impact of these two risk factors may be additive

Cervical dysplasia and high-risk human papillomavirus infections among HIVinfected and HIV-uninfected adolescent females

Background. HIV-infected adolescents may be at higher risk for high-grade cervical lesions than HIV-uninfected adolescents. The purpose of this study was to compare the prevalence of high-risk HPV (HR-HPV) infections and Pap smear abnormalities between these two groups. Methods. In this cross-sectional study, we compared the HPV DNA and Pap smear results between 35 HIVinfected and 50 HIV-uninfected adolescents in order to determine the prevalence of HR-HPV genotypes and cervical cytological abnormalities. Comparisons were made using Pearson 2 and independent-samples t-tests analyses, and associations between demographic and behavioral characteristics and HPV infections were examined. Results. HIV-infected participants were more likely to be infected with any HPV (88.6% versus 48.0%; < 0.001) and with at least one HR-HPV (60.0% versus 24.0%; = 0.001), and to have multiple concurrent HPV infections (68.6% versus 22.0%; < 0.001). HPV 16 and 18 were relatively underrepresented among HR-HPV infections. Abnormal Pap test results were more common among HIV-infected participants (28.8% versus 12.0%; = 0.054). A history of smoking was associated with HR-HPV infection. Conclusions. HIV-infected adolescents have an increased risk of infection with HR-HPV and of Pap test abnormalities. The majority of HR-HPV infections among our participants would not be prevented by the currently available vaccinations against HPV

Peirce's i and Cohen's κ for 2×2 Measures of Rater Reliability

This study examined a historical mixture model approach to the evaluation of ratings made in “gold standard” and two-rater 2×2 contingency tables. Peirce's i and the derived i average were discussed in relation to a widely used index of reliability in the behavioral sciences, Cohen's κ. Sample size, population base rate of occurrence, the true “science of the method”, and guessing rates were manipulated across simulations. In “gold standard” situations, Peirce's i tended to recover the true reliability of ratings as well as better than κ. In two-rater situations, iave tended to recover the true reliability as well as better than κ in most situations. The empirical utility and potential theoretical benefits of mixture model methods in estimating reliability are discussed, as are the associations between the i statistics and other modern mixture model approaches

Feasibility of audit methods to study access to substance use treatment

Audit studies represent an emerging method for examining disparities in access to care, like substance use treatment, whereby fake patients (i.e., actors) attempt to procure a service with one or more characteristics isolated across condition. This allows for manipulation of variables, like insurance status, that are normally fixed or impossible to standardize with precision when studying actual patients. This pilot study explored whether these methods were feasible for the examination of community-based substance use treatment access. Masked telephone calls (n=48) were made to providers (k=8) in a single city seeking an appointment. A male and female patient made calls in three insurance status conditions: no insurance, state-funded insurance, and private insurance. All other subject characteristics were held constant. Results showed an audit design to be a feasible method for examining disparities in access and demonstrated substantial barriers to voluntary treatment. Implications and future directions are discussed