A Pilot Study of an mHealth Application for Healthcare Workers: Poor Uptake Despite High Reported Acceptability at a Rural South African Community-Based MDR-TB Treatment Program

Introduction: As the South African province of KwaZulu-Natal addresses a growing multidrug-resistant tuberculosis (MDR-TB) epidemic by shifting care and treatment from trained specialty centers to community hospitals, delivering and monitoring MDR-TB therapy has presented new challenges. In particular, tracking and reporting adverse clinical events have been difficult for mobile healthcare workers (HCWs), trained health professionals who travel daily to patient homes to administer and monitor therapy. We designed and piloted a mobile phone application (Mobilize) for mobile HCWs that electronically standardized the recording and tracking of MDR-TB patients on low-cost, functional phones. Objective: We assess the acceptability and feasibility of using Mobilize to record and submit adverse events forms weekly during the intensive phase of MDR-TB therapy and evaluate mobile HCW perceptions throughout the pilot period. Methods: All five mobile HCWs at one site were trained and provided with phones. Utilizing a mixed-methods evaluation, mobile HCWs’ usage patterns were tracked electronically for seven months and analyzed. Qualitative focus groups and questionnaires were designed to understand the impact of mobile phone technology on the work environment. Results: Mobile HCWs submitted nine of 33 (27%) expected adverse events forms, conflicting with qualitative results in which mobile HCWs stated that Mobilize improved adverse events communication, helped their daily workflow, and could be successfully expanded to other health interventions. When presented with the conflict between their expressed views and actual practice, mobile HCWs cited forgetfulness and believed patients should take more responsibility for their own care. Discussion This pilot experience demonstrated poor uptake by HCWs despite positive responses to using mHealth. Though our results should be interpreted cautiously because of the small number of mobile HCWs and MDR-TB patients in this study, we recommend carefully exploring the motivations of HCWs and technologic enhancements prior to scaling new mHealth initiatives in resource poor settings

Association of Rideshare-Based Transportation Services and Missed Primary Care Appointments: A Clinical Trial

In a pragmatic trial, offering complimentary ridesharing services broadly to Medicaid patients did not reduce rates of missed primary care appointments. The uptake of free rides was low, and rates of missed appointments remained unchanged at 36%. Efforts to reduce missed appointments due to transportation barriers may require more targeted approaches

Culture Conversion Among HIV Co-Infected Multidrug-Resistant Tuberculosis Patients in Tugela Ferry, South Africa

Little is known about the time to sputum culture conversion in MDR-TB patients co-infected with HIV, although such patients have, historically, had poor outcomes. We describe culture conversion rates among MDR-TB patients with and without HIV-co-infection in a TB-endemic, high-HIV prevalent, resource-limited setting.Patients with culture-proven MDR-TB were treated with a standardized second-line regimen. Sputum cultures were taken monthly and conversion was defined as two negative cultures taken at least one month apart. Time-to-conversion was measured from the day of initiation of MDR-TB therapy. Subjects with HIV received antiretroviral therapy (ART) regardless of CD4 count.Among 45 MDR-TB patients, 36 (80%) were HIV-co-infected. Overall, 40 (89%) of the 45 patients culture-converted within the first six months and there was no difference in the proportion who converted based on HIV status. Median time-to-conversion was 62 days (IQR 48-111). Among the five patients who did not culture convert, three died, one was transferred to another facility, and one refused further treatment before completing 6 months of therapy. Thus, no patients remained persistently culture-positive at 6 months of therapy.With concurrent second-line TB and ART medications, MDR-TB/HIV co-infected patients can achieve culture conversion rates and times similar to those reported from HIV-negative patients worldwide. Future studies are needed to examine whether similar cure rates are achieved at the end of MDR-TB treatment and to determine the optimal use and timing of ART in the setting of MDR-TB treatment

Too Early to Cut Transportation Benefits From Medicaid Enrollees

Some state governments are considering cuts to the non-emergency medical transportation (NEMT) benefit for Medicaid enrollees, and some Federal officials have proposed making this easier. Yet, there is clear demand. In 2015 alone, low-income patients used 59 million rides for medical appointments. NEMT’s future is under threat because evidence that NEMT improves health care access and downstream outcomes is incomplete. Second, it remains largely unknown whether scarce public resources for transportation are being driven to those who benefit from its availability. This knowledge gap is answerable but unknown because of variations in how states administer NEMT. As a result, tracking who uses the services is inconsistent, and states are unable to link NEMT data with health care outcomes. Instead of cutting NEMT benefits, we believe an alternative path involves improved tracking and evaluations of the benefit first. Better informed policy decisions are needed. Otherwise, if policymakers implement blanket reductions in NEMT spending, they run the risk of causing more harm than good

Evaluating the association between the built environment and primary care access for new Medicaid enrollees in an urban environment using Walk and Transit Scores

Worse health outcomes among those living in poverty are due in part to lower rates of health insurance and barriers to care. As the Affordable Care Act reduced financial barriers, identifying persistent barriers to accessible health care continues to be important. We examined whether the built environment as reflected by Walk Score™ (a measure of walkability to neighborhood resources) and Transit Score™ (a measure of transit access) is associated with having a usual source of care among low-income adults, newly enrolled in Medicaid. We received responses from 312 out of 1000 new Medicaid enrollees in Philadelphia, a large, densely populated urban area, who were surveyed between 2015 and 2016 to determine if they had identified a usual source of outpatient primary care. Respondents living at an address with a low Walk Scores (<70) had 84% lower odds of having a usual source of care (OR 0.16, 95% CI 0.04–0.61). Transit scores were not associated with having a usual source of care. Walk Score may be a tool for policy makers and providers of care to identify populations at risk for worse primary care access

Continuity in a VA patient-centered medical home reduces emergency department visits.

One major goal of the Patient-Centered Medical Home (PCMH) is to improve continuity of care between patients and providers and reduce the utilization of non-primary care services like the emergency department (ED).To characterize continuity under the Veterans Health Administration's PCMH model--the Patient Aligned Care Team (PACT), at one large Veterans Affair's (VA's) primary care clinic, determine the characteristics associated with high levels of continuity, and assess the association between continuity and ED visits.Retrospective, observational cohort study of patients at the West Haven VA (WHVA) Primary Care Clinic from March 2011 to February 2012.The 13,495 patients with established care at the Clinic, having at least one visit, one year before March 2011.Our exposure variable was continuity of care--a patient seeing their assigned primary care provider (PCP) at each clinic visit. The outcome of interest was having an ED visit.The patients encompassed 42,969 total clinic visits, and 3185 (24%) of them had 15,458 ED visits. In a multivariable logistic regression analysis, patients with continuity of care--at least one visit with their assigned PCP--had lower ED utilization compared to individuals without continuity (adjusted odds ratio [AOR] 0.54; 95% CI: 0.41, 0.71), controlling for frequency of primary care visits, comorbidities, insurance, distance from the ED, and having a trainee PCP assigned. Likewise, the adjusted rate of ED visits was 544/1000 person-year (PY) for patients with continuity vs. 784/1000 PY for patients without continuity (p = 0.001). Compared to patients with low continuity (<33% of visits), individuals with medium (33-50%) and high (>50%) continuity were less likely to utilize the ED.Strong continuity of care is associated with decreased ED utilization in a PCMH model and improving continuity may help reduce the utilization of non-primary care services

Adjusted Odds Ratio of Association Between ED Visit and Continuity of Care and Levels of Continuity.

<p>The first row illustrates the adjusted odds ratio between ED visits and continuity of care for individuals with at least one visit having continuity with their primary care provider. The second and third rows are the adjusted odds ratio for individuals who had high and medium levels of continuity and are compared to individuals with low levels of continuity, indicated by the asterisk (*).</p

Association Between Levels of Continuity of Care and Emergency Department Utilization for Patients with ≥1 Continuity Visit.

<p>Abbreviations: ED, emergency department; PY, person-year; CI, confidence interval; IQR, interquartile range; OR, odds ratio; AOR, adjusted odds ratio; COPD, chronic obstructive pulmonary disease; TIA, transient ischemic attack; PTSD, post-traumatic stress disorder; ED, emergency department; PCP, primary care provider.</p>a<p>The adjusted model excluded 1289 (9.6%) patients because they were missing one or more variables in the model.</p>b<p>Reference value.</p>c<p>Because of the small number of veterans in these groups, they were combined: active military personnel, CAV/NPS, ChampVA spouse and children, non-Veteran humanitarian groups, merchant marines, and Tricare.</p

Association Between Continuity of Care and Emergency Department Utilization.

<p>Abbreviations: ED, emergency department; PY, per-year; CI, confidence interval; IQR, interquartile range; OR, odds ratio; AOR, adjusted odds ratio; COPD, chronic obstructive pulmonary disease; TIA, transient ischemic attack; PTSD, post-traumatic stress disorder; ED, emergency department; PCP, primary care provider.</p>a<p>The adjusted model excluded 1289 (9.6%) patients because they were missing one or more variables in the model.</p>b<p>Continuity of care levels were excluded because of potential for colinearity with the main outcome of interest, overall continuity.</p>c<p>Reference value.</p>d<p>Because of the small number of veterans in these groups, they were combined: active military personnel, CAV/NPS, ChampVA spouse and children, non-Veteran humanitarian groups, merchant marines, and Tricare.</p

Patient Demographics by Continuity and Stratification by Continuity of Care Levels.

<p>Abbreviations: IQR, interquartile range; MI, myocardial infarction; COPD, chronic obstructive pulmonary disease; TIA, transient ischemic attack; PTSD, post-traumatic stress disorder; ED, emergency department.</p>a<p>Sixty-nine percent were missing this variable.</p>b<p>Composite of major depression, bipolar, schizophrenia and PTSD.</p>c<p>Because of the small number of veterans in these groups, they were combined: active military personnel, CAV/NPS, ChampVA spouse and children, non-Veteran humanitarian groups, merchant marines, and Tricare.</p>d<p>Among ED visits that took place between Monday and Friday.</p