Changes to Racial Disparities in Readmission Rates After Medicare’s Hospital Readmissions Reduction Program Within Safety-Net and Non-Safety-Net Hospitals

After the Medicare Hospital Readmissions Reduction Program began enforcing financial penalties, disparities in readmissions between white and black patients widened at safety-net hospitals for conditions not targeted by the program. Disparities were stable for conditions targeted by the program. At non-safety-net hospitals, disparities were unchanged for both targeted and non-targeted conditions

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

Nudging New York: adaptive models and the limits of behavioral interventions to reduce no-shows and health inequalities

Background Missed healthcare appointments (no-shows) are costly and operationally inefficient for health systems. No-show rates are particularly high for vulnerable populations, even though these populations often require additional care. Few studies on no-show behavior or potential interventions exist specifically for Federally Qualified Health Centers (FQHCs), which care for over 24 million disadvantaged individuals in the United States. The purpose of this study is to identify predictors of no-show behavior and to analyze the effects of a reminder intervention in urban FQHCs in order to design effective policy solutions to a protracted issue in healthcare. Methods This is a retrospective observational study using electronic medical record data from 11 facilities belonging to a New York City-based FQHC network between June 2017 to April 2018. This data includes 53,149 visits for 41,495 unique patients. Seven hierarchical generalized linear models and generalized additive models were used to predict no-shows, and multiple regression models evaluated the effectiveness of a reminder. All analyses were conducted in R. Results The strongest predictor of no-show rates in FQHCs is whether or not patients are assigned to empaneled providers (z = − 91.45, p < 10− 10), followed by lead time for appointments (z = 23.87, p < 10− 10). These effects were fairly stable across facilities. The reminder had minimal effects on no-show rates overall (No show rate before: 41.6%, after: 42.1%). For individuals with appointments before and after the reminder, there was a small decrease in no-shows of 2%. Conclusions The limited effects of the reminder intervention suggest the need for more personalized behavioral interventions to reduce no-shows. We recommend that these begin with increasing the use of empaneled providers for preventive care appointments and reducing the lag time between setting the appointment and the actual date of the appointment, at least for individuals with a high rate of no-show. By complementing these with low-intensity, low-cost behavioral interventions, we would expect greater impacts for improved access to care, contributing to the well-being of vulnerable populations

Validating Five Questions of Antiretroviral Nonadherence in a Public-Sector Treatment Program in Rural South Africa

Simple questions are the most commonly used measures of antiretroviral treatment (ART) adherence in sub-Saharan Africa (SSA), but rarely validated. We administered five adherence questions in a public-sector primary care clinic in rural South Africa: 7-day recall of missed doses, 7-day recall of late doses, a six-level Likert item, a 30-day visual analogue scale of the proportion of doses missed, and recall of the time when an ART dose was last missed. We estimated question sensitivity and specificity in detecting immunologic (or virologic) failure assessed within 45 days of the adherence question date. Of 165 individuals, 7% had immunologic failure; 137 individuals had viral loads with 9% failure detected. The Likert item performed best for immunologic failure with sensitivity/specificity of 100%/5% (when defining nonadherence as self-reported adherence less than -excellent-), 42%/55% (less than -very good-), and 25%/95% (less than -good-). The remaining questions had sensitivities <=17%, even when the least strict cutoffs defined nonadherence. When we stratified the analysis by gender, age, or education, question performance was not substantially better in any of the subsamples in comparison to the total sample. Five commonly used adherence questions performed poorly in identifying patients with treatment failure in a public-sector ART program in SSA. Valid adherence measurement instruments are urgently required to identify patients needing treatment support and those most at risk of treatment failure. Available estimates of ART adherence in SSA are mostly based on studies using adherence questions. It is thus unlikely that our understanding of ART adherence in the region is correct.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/90502/1/apc-2E2010-2E0257.pd

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

Rationale and protocol for a cluster randomized pragmatic clinical trial testing behavioral economic implementation strategies to improve tobacco treatment rates for cancer patients who smoke

Background Routine evidence-based tobacco use treatment minimizes cancer-specific and all-cause mortality, reduces treatment-related toxicity, and improves quality of life among patients receiving cancer care. Few cancer centers employ mechanisms to systematically refer patients to evidence-based tobacco cessation services. Implementation strategies informed by behavioral economics can increase tobacco use treatment engagement within oncology care. Methods A four-arm cluster-randomized pragmatic trial will be conducted across nine clinical sites within the Implementation Science Center in Cancer Control Implementation Lab to compare the effect of behavioral economic implementation strategies delivered through embedded messages (or “nudges”) promoting patient engagement with the Tobacco Use Treatment Service (TUTS). Nudges are electronic medical record (EMR)-based messages delivered to patients, clinicians, or both, designed to counteract known patient and clinician biases that reduce treatment engagement. We used rapid cycle approaches (RCA) informed by relevant stakeholder experiences to refine and optimize our implementation strategies and methods prior to trial initiation. Data will be obtained via the EMR, clinician survey, and semi-structured interviews with a subset of clinicians and patients. The primary measure of implementation is penetration, defined as the TUTS referral rate. Secondary outcome measures of implementation include patient treatment engagement (defined as the number of patients who receive FDA-approved medication or behavioral counseling), quit attempts, and abstinence rates. The semi-structured interviews, guided by the Consolidated Framework for Implementation Research, will assess contextual factors and patient and clinician experiences with the nudges. Discussion This study will be the first in the oncology setting to compare the effectiveness of nudges to clinicians and patients, both head-to-head and in combination, as implementation strategies to improve TUTS referral and engagement. We expect the study to (1) yield insights into the effectiveness of nudges as an implementation strategy to improve uptake of evidence-based tobacco use treatment within cancer care, and (2) advance our understanding of the multilevel contextual factors that drive response to these strategies. These results will lay the foundation for how patients with cancer who smoke are best engaged in tobacco use treatment and may lead to future research focused on scaling this approach across diverse centers. Trial registration Clinicaltrials.gov, NCT04737031 . Registered 3 February 2021

Behavioral economic implementation strategies to improve serious illness communication between clinicians and high-risk patients with cancer: protocol for a cluster randomized pragmatic trial

Background Serious illness conversations (SICs) are an evidence-based approach to eliciting patients’ values, goals, and care preferences that improve patient outcomes. However, most patients with cancer die without a documented SIC. Clinician-directed implementation strategies informed by behavioral economics (“nudges”) that identify high-risk patients have shown promise in increasing SIC documentation among clinicians. It is unknown whether patient-directed nudges that normalize and prime patients towards SIC completion—either alone or in combination with clinician nudges that additionally compare performance relative to peers—may improve on this approach. Our objective is to test the effect of clinician- and patient-directed nudges as implementation strategies for increasing SIC completion among patients with cancer. Methods We will conduct a 2 × 2 factorial, cluster randomized pragmatic trial to test the effect of nudges to clinicians, patients, or both, compared to usual care, on SIC completion. Participants will include 166 medical and gynecologic oncology clinicians practicing at ten sites within a large academic health system and their approximately 5500 patients at high risk of predicted 6-month mortality based on a validated machine-learning prognostic algorithm. Data will be obtained via the electronic medical record, clinician survey, and semi-structured interviews with clinicians and patients. The primary outcome will be time to SIC documentation among high-risk patients. Secondary outcomes will include time to SIC documentation among all patients (assessing spillover effects), palliative care referral among high-risk patients, and aggressive end-of-life care utilization (composite of chemotherapy within 14 days before death, hospitalization within 30 days before death, or admission to hospice within 3 days before death) among high-risk decedents. We will assess moderators of the effect of implementation strategies and conduct semi-structured interviews with a subset of clinicians and patients to assess contextual factors that shape the effectiveness of nudges with an eye towards health equity. Discussion This will be the first pragmatic trial to evaluate clinician- and patient-directed nudges to promote SIC completion for patients with cancer. We expect the study to yield insights into the effectiveness of clinician and patient nudges as implementation strategies to improve SIC rates, and to uncover multilevel contextual factors that drive response to these strategies. Trial registration ClinicalTrials.gov , NCT04867850 . Registered on April 30, 2021. Funding National Cancer Institute P50CA24469

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

The Impact of Fully-Subsidized Transit Passes on Health and Well-Being for People with Low Incomes

In October 2020, King County Metro Transit launched asubsidized annual transit pass program to provide annual transit passes to people with incomes ≤80% of the Federal Poverty Level (FPL) who also receive cash public benefits. The annual pass allows the holder to ride public transit without paying a fare. The project team is evaluating the impact of King County’s annual pass program on health and well-being. The team will also look specifically at outcomes by race to understand whether the impacts of the annual pass are racially equitable