43 research outputs found

    Short- and long-term associations between widowhood and mortality in the United States: longitudinal analyses

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    Background Past research shows that spousal death results in elevated mortality risk for the surviving spouse. However, most prior studies have inadequately controlled for socioeconomic status (SES), and it is unclear whether this ‘widowhood effect’ persists over time. Methods Health and Retirement Study participants aged 50+ years and married in 1998 (n = 12 316) were followed through 2008 for widowhood status and mortality (2912 deaths). Discrete-time survival analysis was used to compare mortality for the widowed versus the married. Results Odds of mortality during the first 3 months post-widowhood were significantly higher than in the continuously married (odds ratio (OR) for men = 1.87, 95% CI: 1.27, 2.75; OR for women = 1.47, 95% CI: 0.96, 2.24) in models adjusted for age, gender, race and baseline SES (education, household wealth and household income), behavioral risk factors and co-morbidities. Twelve months following bereavement, men experienced borderline elevated mortality (OR = 1.16, 95% CI: 1.00, 1.35), whereas women did not (OR = 1.07, 95% CI: 0.90, 1.28), though the gender difference was non-significant. Conclusion The ‘widowhood effect’ was not fully explained by adjusting for pre-widowhood SES and particularly elevated within the first few months after widowhood. These associations did not differ by sex

    Outcomes of the Botswana national HIV/AIDS treatment programme from 2002 to 2010: a longitudinal analysis

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    Background Short-term mortality rates among patients with HIV receiving antiretroviral therapy (ART) in sub- Saharan Africa are higher than those recorded in high-income countries, but systematic long-term comparisons have not been made because of the scarcity of available data. We analysed the eff ect of the implementation of Botswana’s national ART programme, known as Masa, from 2002 to 2010. Methods The Masa programme started on Jan 21, 2002. Patients who were eligible for ART according to national guidelines had their data collected prospectively through a clinical information system developed by the Botswana Ministry of Health. A dataset of all available electronic records for adults (≥18 years) who had enrolled by April 30, 2010, was extracted and sent to the study team. All data were anonymised before analysis. The primary outcome was mortality. To assess the eff ect of loss to follow-up, we did a series of sensitivity analyses assuming varying proportions of the population lost to follow-up to be dead. Findings We analysed the records of 126 263 patients, of whom 102 713 had documented initiation of ART. Median follow-up time was 35 months (IQR 14–56), with a median of eight follow-up visits (4–14). 15 270 patients were deemed lost to follow-up by the end of the study. 63% (78 866) of the study population were women; median age at baseline was 34 years for women (IQR 29–41) and 38 years for men (33–45). 10 230 (8%) deaths were documented during the 9 years of the study. Mortality was highest during the fi rst 3 months after treatment initiation at 12·8 deaths per 100 person-years (95% CI 12·4–13·2), but decreased to 1·16 deaths per 100 person-years (1·12–1·2) in the second year of treatment, and to 0·15 deaths per 100 person-years (0·09–0·25) over the next 7 years of follow-up. In each calendar year after the start of the Masa programme in 2002, average CD4 cell counts at enrolment increased (from 101 cells/μL [IQR 44–156] in 2002, to 191 cells/μL [115–239] in 2010). In each year, the proportion of the total enrolled population who died in that year decreased, from 63% (88 of 140) in 2002, to 0·8% (13 of 1599) in 2010. A sensitivity analysis assuming that 60% of the population lost to follow-up had died gave 3000 additional deaths, increasing overall mortality from 8% to 11–13%. Interpretation The Botswana national HIV/AIDS treatment programme reduced mortality among adults with HIV to levels much the same as in other low-income or middle-income countries

    Undergoing Transformation to the Patient Centered Medical Home in Safety Net Health Centers: Perspectives from the Front Lines

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    Objectives—Safety Net Health Centers (SNHCs), which include Federally Qualified Health Centers (FQHCs) provide primary care for underserved, minority and low income patients. SNHCs across the country are in the process of adopting the Patient Centered Medical Home (PCMH) model, based on promising early implementation data from demonstration projects. However, previous demonstration projects have not focused on the safety net and we know little about PCMH transformation in SNHCs. Design—This qualitative study characterizes early PCMH adoption experiences at SNHCs. Setting and Participants—We interviewed 98 staff,(administrators, providers, and clinical staff) at 20 of 65 SNHCs, from five states, who were participating in the first of a five-year PCMH collaborative, the Safety Net Medical Home Initiative. Main Measures—We conducted 30-45 minute, semi-structured telephone interviews. Interview questions addressed benefits anticipated, obstacles encountered, and lessons learned in transition to PCMH. Results—Anticipated benefits for participating in the PCMH included improved staff satisfaction and patient care and outcomes. Obstacles included staff resistance and lack of financial support for PCMH functions. Lessons learned included involving a range of staff, anticipating resistance, and using data as frequent feedback. Conclusions—SNHCs encounter unique challenges to PCMH implementation, including staff turnover and providing care for patients with complex needs. Staff resistance and turnover may be ameliorated through improved healthcare delivery strategies associated with the PCMH. Creating predictable and continuous funding streams may be more fundamental challenges to PCMH transformation
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