Publications

BACKGROUND

Anaemia commonly complicates both human immunodeficiency virus (HIV) infection and tuberculosis (TB), contributing substantially to morbidity and mortality. The mechanisms underlying anaemia and corresponding treatments in co-infected patients are poorly defined.

OBJECTIVE

To determine the relative contributions of anaemia of chronic disease (ACD) and iron deficiency to anaemia in patients with HIV-associated TB.

DESIGN

Consecutively recruited hospitalised (n = 102) and matched ambulatory patients (n = 51) with microbiologically confirmed HIV-associated TB in Cape Town, South Africa, were included. Haemoglobin levels, iron status markers, hepcidin and pro-inflammatory cytokines in blood were measured. We determined the prevalence of ACD and iron-deficiency anaemia (IDA) using seven different published definitions of IDA.

RESULTS

More than 80% of enrolled HIV-associated TB patients were anaemic, and anaemia was more severe among in-patients. Over 95% of anaemic HIV-associated TB patients had ACD, whereas the proportion with IDA using a range of seven different definitions was low overall (median <3%, range 0-32.6) in both patient groups. The proportion with IDA and hepcidin concentration ⩿ 20.0 ng/ml (predictive of responsiveness to oral iron supplementation) was also very low (median <3%, range 0-15.1).

CONCLUSIONS

ACD was the predominant cause underlying anaemia in HIV-associated TB patients, and IDA was very uncommon in this setting. The majority of anaemic HIV-associated TB patients were unlikely to benefit from oral iron supplementation.

There were over 23,000 opioid overdose deaths in the USA in 2013, and opioid-related mortality is increasing. Increased access to naloxone, particularly through community-based lay naloxone distribution, is a widely supported strategy to reduce opioid overdose mortality; however, little is known about the ecological and spatial patterns of the distribution and utilization of lay naloxone. This study aims to investigate the neighborhood-level correlates and spatial relationships of lay naloxone distribution and utilization and opioid overdose deaths. We determined the locations of lay naloxone distribution sites and the number of unintentional opioid overdose deaths and reported reversal events in San Francisco census tracts (n = 195) from 2010 to 2012. We used Wilcoxon rank-sum tests to compare census tract characteristics across tracts adjacent and not adjacent to distribution sites and multivariable negative binomial regression models to assess the association between census tract characteristics, including distance to the nearest site, and counts of opioid overdose deaths and naloxone reversal events. Three hundred forty-two opioid overdose deaths and 316 overdose reversals with valid location data were included in our analysis. Census tracts including or adjacent to a distribution site had higher income inequality, lower percentage black or African American residents, more drug arrests, higher population density, more overdose deaths, and more reversal events (all p < 0.05). In multivariable analysis, greater distance to the nearest distribution site (up to a distance of 4000 m) was associated with a lower count of Naloxone reversals [incidence rate ratio (IRR) = 0.51 per 500 m increase, 95% CI 0.39-0.67, p < 0.001] but was not significantly associated with opioid overdose deaths. These findings affirm that locating lay naloxone distribution sites in areas with high levels of substance use and overdose risk facilitates reversals of opioid overdoses in those immediate areas but suggests that alternative delivery methods may be necessary to reach individuals in other areas with less concentrated risk.

PURPOSE

Transgender people have difficulty accessing gender-affirming hormone therapy (HT), a medically necessary treatment, in part due to a lack of provider knowledge. Patients often seek information on gender-affirming medical care using the Internet. Patients who are better informed about their own care may receive better care. This study evaluated the quantity and quality of online information about HT using several existing and novel measures.

METHODS

Structured Google searches were conducted. Sites were evaluated using previously described Journal of the American Medical Association (JAMA), DISCERN, and Health On the Net (HON) criteria, for citation of the Endocrine Society Guidelines and the World Professional Association for Transgender Health (WPATH) Standards of Care (SOC), and other topic-specific measures.

RESULTS

Forty sites were evaluated. The median JAMA score was 3.5/7, and the median DISCERN score was 51/80. No sites held HON certification. Citation of the Endocrine Society Guidelines and the WPATH SOC was inconsistent. Institutional sites had higher DISCERN scores compared with other sites. The presence of a bibliography was most associated with measures of quality.

CONCLUSION

The quality of online information about HT is inconsistent and limited in quantity. Development of reliable online resources on HT for transgender patients is essential. Broadening awareness of key guidelines from the Endocrine Society and WPATH is essential.

BACKGROUND

Evidence-based quality improvement (EBQI) methods may facilitate practice redesign for more effective implementation of the patient-centered medical home (PCMH).

OBJECTIVE

We assessed changes in health care utilization and costs for patients receiving care from practices using an EBQI approach to implement PCMH and comparison practices over a 5-year period.

RESEARCH DESIGN

We used longitudinal, electronic data from patients in 6 practices using EBQI and 28 comparison practices implementing standard PCMH for 1 year before and 4 years after PCMH implementation. We analyzed trends in utilization and costs using bivariate analyses and independent effects of EBQI status on outcomes using multivariate regressions adjusting for year, patient and clinic factors, and patient random effects for repeated measures.

SUBJECTS

A total of 136,856 patients using Veterans Affairs primary care.

MEASURES

Veterans Affairs ambulatory care encounters, emergency department visits, admissions, and total health care costs per patient.

RESULTS

After PCMH implementation, overall utilization for primary care, specialty care, and mental health/substance abuse care decreased, whereas utilization for telephone care increased among all practices. Patients also had fewer hospitalizations and lower costs per patient. In adjusted analyses, EBQI practice was independently associated with fewer primary care (IRR=0.85), specialty care (IRR=0.83), and mental health care encounters (IRR=0.69); these effects attenuated over time (all P<0.01). There was no independent effect of EBQI on prescription drug use, acute care, health care costs, or mortality rate relative to comparison practices.

CONCLUSION

EBQI methods enhanced the effects of PCMH implementation by reducing ambulatory care while increasing non-face-to-face care.