Community-Based Settings and Sampling Strategies: Implications for Reducing Racial Health Disparities Among Black Men, New York City, 2010–2013

Introduction Rates of screening colonoscopies, an effective method of preventing colorectal cancer, have increased in New York City over the past decade, and racial disparities in screening have declined. However, vulnerable subsets of the population may not be reached by traditional surveillance and intervention efforts to improve colorectal cancer screening rates. Methods We compared rates of screening colonoscopies among black men aged 50 or older from a citywide random-digit–dial sample and a location-based sample focused on hard-to-reach populations to evaluate the representativeness of the random-digit–dial sample. The location-based sample (N = 5,568) was recruited from 2010 through 2013 from community-based organizations in New York City. Descriptive statistics were used to compare these data with data for all black men aged 50 or older from the 2011 cohort of the Community Health Survey (weighted, N = 334) and to compare rates by community-based setting. Results Significant differences in screening colonoscopy history were observed between the location-based and random-digit–dial samples (49.1% vs 62.8%, P \u3c .001). We observed significant differences between participants with and without a working telephone among the location-based sample and between community-based settings. Conclusions Vulnerable subsets of the population such as those with inconsistent telephone access are excluded from random-digit–dial samples. Practitioners and researchers should consider the target population of proposed interventions to address disparities, and whether the type of setting reaches those most in need of services

Integrating tuberculosis and HIV services in low- and middle-income countries: a systematic review.

OBJECTIVES: Given the imperative to scale up integrated tuberculosis (TB) and HIV services in settings where both are of major public health importance, we aimed to synthesise knowledge concerning implementation of TB/HIV service integration. METHODS: Systematic review of studies describing a strategy to facilitate TB and HIV service integration, searching 15 bibliographic databases including Medline, Embase and the Cochrane library; and relevant conference abstracts. RESULTS: Sixty-three of 1936 peer-reviewed articles and 70 of 170 abstracts met our inclusion criteria. We identified five models: entry via TB service, with referral for HIV testing and care; entry via TB service, on-site HIV testing, and referral for HIV care; entry via HIV service with referral for TB screening and treatment; entry via HIV service, on-site TB screening, and referral for TB diagnosis and treatment; and TB and HIV services provided at a single facility. Referral-based models are most easily implemented, but referral failure is a key risk. Closer integration requires more staff training and additional infrastructure (e.g. private space for HIV counselling; integrated records). Infection control is a major concern. More integrated models hold potential efficiencies from both provider and user perspective. Most papers report 'outcomes' (e.g. proportion of TB patients tested for HIV); few report downstream 'impacts' such as outcomes of TB treatment or antiretroviral therapy. Very few studies address the perspectives of service users or staff, or costs or cost-effectiveness. CONCLUSIONS: While scaling up integrated services, robust comparisons of the impacts of different models are needed using standardised outcome measures

Is there scope for cost savings and efficiency gains in HIV services? A systematic review of the evidence from low- and middle-income countries.

OBJECTIVE: To synthesize the data available--on costs, efficiency and economies of scale and scope--for the six basic programmes of the UNAIDS Strategic Investment Framework, to inform those planning the scale-up of human immunodeficiency virus (HIV) services in low- and middle-income countries. METHODS: The relevant peer-reviewed and "grey" literature from low- and middle-income countries was systematically reviewed. Search and analysis followed Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. FINDINGS: Of the 82 empirical costing and efficiency studies identified, nine provided data on economies of scale. Scale explained much of the variation in the costs of several HIV services, particularly those of targeted HIV prevention for key populations and HIV testing and treatment. There is some evidence of economies of scope from integrating HIV counselling and testing services with several other services. Cost efficiency may also be improved by reducing input prices, task shifting and improving client adherence. CONCLUSION: HIV programmes need to optimize the scale of service provision to achieve efficiency. Interventions that may enhance the potential for economies of scale include intensifying demand-creation activities, reducing the costs for service users, expanding existing programmes rather than creating new structures, and reducing attrition of existing service users. Models for integrated service delivery--which is, potentially, more efficient than the implementation of stand-alone services--should be investigated further. Further experimental evidence is required to understand how to best achieve efficiency gains in HIV programmes and assess the cost-effectiveness of each service-delivery model

Efficacy and safety results from IMblaze370, a randomised Phase III study comparing atezolizumab+cobimetinib and atezolizumab monotherapy vs regorafenib in chemotherapy-refractory metastatic colorectal cancer

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Nurses’ knowledge of tuberculosis, HIV, and integrated HIV/TB care policies in rural Western Cape, South Africa

HIV and tuberculosis (TB) co-infection remain the leading causes of mortality in many developing countries. Several policies for their prevention and management exist; however, progress to meet the World Health Organization’s indicators is slow. As nurses in rural areas are the main health care professionals responsible for the implementation of policies, questions arose about nursing knowledge regarding TB and HIV policies. A concurrent mixed method research approach was used to investigate this issue in a rural area of the Western Cape in South Africa. After a two-step sampling process, data were collected through 44 questionnaires and 12 interviews. We used descriptive and inferential statistics as well as content analysis methods. We found that most of the nurses had insufficient knowledge on certain aspects of policy guidelines that included medications, intensive case findings, and management of multidrug-resistant TB. It is recommended that training be intensified to improve implementation of policies

Factors influencing uptake and timing of risk reducing salpingo-oophorectomy in women at risk of familial ovarian cancer: a competing risk time to event analysis

Objective To evaluate factors affecting uptake of risk-reducing salpingo-oophorectomy (RRSO) over time in women at high-risk of familial ovarian cancer. Design Prospective observational cohort. Setting Tertiary high-risk familial gynaecological cancer clinic. Population/sample New clinic attendees between March 2004 and November 2009, fulfilling the high-risk criteria for the UK Familial Ovarian Cancer Screening Study. Methods Risk management options discussed included RRSO and ovarian surveillance. Outcome data were analysed from a bespoke database. The competing risk method was used to model the cumulative incidence function (CIF) of RRSO over time, and the sub-hazard ratio (SHR) was used to assess the strength of the association of variables of interest with RRSO. Gray's test was used to evaluate the difference in CIF between two groups and multivariable competing risk regression analysis was used to model the cumulative probabilities of covariates on the CIF. Results Of 1133 eligible women, 265 (21.4%) opted for RRSO and 868 (69.9%) chose screening. Women undergoing RRSO were older (49 years, interquartile range 12.2 years) than those preferring screening (43.4 years, interquartile range 11.9 years) (P < 0.0005). The CIF for RRSO at 5 years was 0.55 (95% CI 0.45-0.64) for BRCA1/2 carriers and 0.22 (95% CI 0.19-0.26) for women of unknown mutation status (P < 0.0001); 0.42 (95% CI 0.36-0.47) for postmenopausal women (P < 0.0001); 0.29 (95% CI 0.25-0.33) for parity ≤1 (P = 0.009) and 0.47 (95% CI 0.39-0.55) for a personal history of breast cancer (P < 0.0001). Variables of significance from the regression analysis were: a BRCA1/2 mutation (SHR 2.31, 95% CI 1.7-3.14), postmenopausal status (SHR 2.16, 95% CI 1.62-2.87)) and a personal history of breast cancer (SHR 1.5, 95% CI 1.09-2.06). Conclusions Decision-making is a complex process and women opt for surgery many years after initial risk assessment. BRCA carriers, postmenopausal women and women who had breast cancer are significantly more likely to opt for preventative surgery. © 2012 RCOG

Examining the influence of country-level and health system factors on nursing and physician personnel production.

BackgroundA key component to achieving good patient outcomes is having the right type and number of healthcare professionals with the right resources. Lack of investment in infrastructure required for producing and retaining adequate numbers of health professionals is one reason, and contextual factors related to socioeconomic development may further explain the trend. Therefore, this study sought to explore the relationships between country-level contextual factors and healthcare human resource production (defined as worker-to-population ratio) across 184 countries.MethodsThis exploratory observational study is grounded in complexity theory as a guiding framework. Variables were selected through a process that attempted to choose macro-level indicators identified by the interdisciplinary literature as known or likely to affect the number of healthcare workers in a country. The combination of these variables attempts to account for the gender- and class-sensitive identities of physicians and nurses. The analysis consisted of 1 year of publicly available data, using the most recently available year for each country where multiple regressions assessed how context may influence health worker production. Missing data were imputed using the ICE technique in STATA and the analyses rerun in R as an additional validity and rigor check.ResultsThe models explained 63 % of the nurse/midwife-to-population ratio (pseudo R (2) = 0.627, p = 0.0000) and 73 % of the physician-to-population ratio (pseudo R (2) = 0.729, p = 0.0000). Average years of school in a country's population, emigration rates, beds-per-1000 population, and low-income country statuses were consistently statistically significant predictors of production, with percentage of public and private sector financing of healthcare showing mixed effects.ConclusionsOur study demonstrates that the strength of political, social, and economic institutions does impact human resources for health production and lays a foundation for studying how macro-level contextual factors influence physician and nurse workforce supply. In particular, the results suggest that public and private investments in the education sector would provide the greatest rate of return to countries. The study offers a foundation from which longitudinal analyses can be conducted and identifies additional data that may help enhance the robustness of the models