Patient-centered Strategies Research Articles

HIV Testing and Treatment with the Use of a Community Health Approach in Rural Africa

BackgroundUniversal antiretroviral therapy (ART) with annual population testing and a multidisease, patient-centered strategy could reduce new human immunodeficiency virus (HIV) infections and improve community health.MethodsWe randomly assigned 32 rural communities in Uganda and Kenya to baseline HIV and multidisease testing and national guideline–restricted ART (control group) or to baseline testing plus annual testing, eligibility for universal ART, and patient-centered care (intervention group). The primary end point was the cumulative incidence of HIV infection at 3 years. Secondary end points included viral suppression, death, tuberculosis, hypertension control, and the change in the annual incidence of HIV infection (which was evaluated in the intervention group only).ResultsA total of 150,395 persons were included in the analyses. Population-level viral suppression among 15,399 HIV-infected persons was 42% at baseline and was higher in the intervention group than in the control group at 3 years (79% vs. 68%; relative prevalence, 1.15; 95% confidence interval [CI], 1.11 to 1.20). The annual incidence of HIV infection in the intervention group decreased by 32% over 3 years (from 0.43 to 0.31 cases per 100 person-years; relative rate, 0.68; 95% CI, 0.56 to 0.84). However, the 3-year cumulative incidence (704 incident HIV infections) did not differ significantly between the intervention group and the control group (0.77% and 0.81%, respectively; relative risk, 0.95; 95% CI, 0.77 to 1.17). Among HIV-infected persons, the risk of death by year 3 was 3% in the intervention group and 4% in the control group (0.99 vs. 1.29 deaths per 100 person-years; relative risk, 0.77; 95% CI, 0.64 to 0.93). The risk of HIV-associated tuberculosis or death by year 3 among HIV-infected persons was 4% in the intervention group and 5% in the control group (1.19 vs. 1.50 events per 100 person-years; relative risk, 0.79; 95% CI, 0.67 to 0.94). At 3 years, 47% of adults with hypertension in the intervention group and 37% in the control group had hypertension control (relative prevalence, 1.26; 95% CI, 1.15 to 1.39).ConclusionsUniversal HIV treatment did not result in a significantly lower incidence of HIV infection than standard care, probably owing to the availability of comprehensive baseline HIV testing and the rapid expansion of ART eligibility in the control group. (Funded by the National Institutes of Health and others; SEARCH ClinicalTrials.gov number, NCT01864603.)

A pragmatic patient-reported outcome strategy for rare disease clinical trials: application of the EORTC item library to myelodysplastic syndromes, chronic myelomonocytic leukemia, and acute myeloid leukemia

BackgroundNovel, pragmatic, patient-centered strategies are needed to ensure fit-for-purpose patient-reported outcomes (PRO) instruments in clinical trial research for rare diseases such as myelodysplastic syndromes (MDS), acute myeloid leukemia (AML), and chronic myelomonocytic leukemia (CMML). The objective of the current study was to select supplemental items to add to the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life-Core 30 (QLQ-C30) to ensure content coverage of all important clinical concepts in patients with higher-risk (HR) MDS, low-blast count (LB) AML, and CMML, thus, improving the instrument’s ability to detect clinically meaningful treatment benefit for this context of use.MethodsOur mixed methods approach comprised literature review, clinician consultation (n = 3), and qualitative and quantitative analysis of two stages of patient interview data (n = 14, n = 18) to select library bank items to supplement a generic cancer PRO, the EORTC QLQ-C30.ResultsUnique symptom (n = 54) and impact (n = 72) concepts were organized into conceptual frameworks of treatment benefit, compared with EORTC QLQ-C30 items and conceptual gaps identified. Supplemental items (n = 13) addressing those gaps were selected from the EORTC Item Library and tested with patients. Supplemental item endorsement frequencies met World Health Organization Quality of Life criteria, suggesting good targeting and relevance for this sample. However, three supplemental items were confirmed as problematic based upon cognitive debriefing results, and expert clinical consultations. Ultimately, 10 supplemental items (n = 7 symptom; n = 3 impact) were selected for the MDS/AML/CMML context.ConclusionSupplemental items were selected to enhance the conceptual coverage of the EORTC QLQ-C30 in the areas of fatigue, shortness of breath, and functioning.

The Effects of Anesthesia on the Pediatric Developing Brain: Strategies to Reduce Anesthesia Use in Pediatric MRI and Nursing's Role in Driving Patient Safety

To describe the physiological and biological principles of anesthesia for children; nonanesthesia practices; the state of the evidence of patient- and family-centered care strategies to reduce anesthesia use; and role of nursing in ensuring patient safety through reducing anesthesia use for pediatric magnetic resonance imaging (MRI). Integrative literature review. Review and synthesis of experimental and nonexperimental literature. Anesthesia use in pediatric MRI: 20 studies met inclusion criteria. Physiological and biological side effects of anesthesia in children are substantial. Of significance is the developing research on the extent to which anesthesia affects the developing brain of children. Nonanesthesia in pediatric MRI: 16 studies met inclusion criteria. Common themes were noted between patient- and family-centered care strategies and reducing anesthesia use in children requiring MRI. There are significant risks associated with anesthesia on the developing brain. Nurses play an important role in using patient-centered strategies to reduce pediatric anesthesia use and advocate for patient safety.

Comunicare la Malattia Renale Cronica

In the last sixty years chronic kidney disease (CKD) has emerged as a life-threatening problem with a mortality comparable to that of cancer in spite of the fact that dialysis and transplantation represent effective strategies to grant decades of life to persons who have lost their kidney function. Receiving a diagnosis of CKD is immediately perceived as a long lasting disease with many losses and dependencies and generally associated with a poor quality of life. The support of CKD patients starts at the time of the breaking the bad new and is needed life long, thus communication between patients and their caring teams is central. A patient-centered strategy is mandatory. Listening them, making time to understand their histories and to learn from their experience is the base on which the carer outlines the trajectory of the disease. Generating and supporting hope is an effective strategy having in mind that, as Thomas Aquinas said in the 14th century, to instill hope there must be, although minimal, possibility of success. The possibility is not zero as shown by the reported history of Professor Robert A.J. Eady who discovered albumin in his urine at age of nine years, and subsequently received dialysis and a transplant for more than 50 years and at the same time developed a successful academic career as dermatologist. The complexity of the process in meeting patient’s needs is evident and requires knowledge and respect for patient’s goals. Building with the patient a strong relationship is a sine qua non.

Using health coaching to improve patients' BP management.

Nurses have unique opportunities to influence patient outcomes and reduce healthcare expenditures. Health coaching is one patient-centered strategy nurses can use to improve the limited health literacy often associated with hypertension. This article describes the use of health coaching to help patients understand their medications and give them the knowledge, skills, and confidence to self-manage their hypertension.

Evaluation of RESPOND, a patient-centred program to prevent falls in older people presenting to the emergency department with a fall: A randomised controlled trial.

BackgroundFalls are a leading reason for older people presenting to the emergency department (ED), and many experience further falls. Little evidence exists to guide secondary prevention in this population. This randomised controlled trial (RCT) investigated whether a 6-month telephone-based patient-centred program—RESPOND—had an effect on falls and fall injuries in older people presenting to the ED after a fall.Methods and findingsCommunity-dwelling people aged 60–90 years presenting to the ED with a fall and planned for discharge home within 72 hours were recruited from two EDs in Australia. Participants were enrolled if they could walk without hands-on assistance, use a telephone, and were free of cognitive impairment (Mini-Mental State Examination > 23). Recruitment occurred between 1 April 2014 and 29 June 2015. Participants were randomised to receive either RESPOND (intervention) or usual care (control). RESPOND comprised (1) home-based risk assessment; (2) 6 months telephone-based education, coaching, goal setting, and support for evidence-based risk factor management; and (3) linkages to existing services. Primary outcomes were falls and fall injuries in the 12-month follow-up. Secondary outcomes included ED presentations, hospital admissions, fractures, death, falls risk, falls efficacy, and quality of life. Assessors blind to group allocation collected outcome data via postal calendars, telephone follow-up, and hospital records. There were 430 people in the primary outcome analysis—217 randomised to RESPOND and 213 to control. The mean age of participants was 73 years; 55% were female. Falls per person-year were 1.15 in the RESPOND group and 1.83 in the control (incidence rate ratio [IRR] 0.65 [95% CI 0.43–0.99]; P = 0.042). There was no significant difference in fall injuries (IRR 0.81 [0.51–1.29]; P = 0.374). The rate of fractures was significantly lower in the RESPOND group compared with the control (0.05 versus 0.12; IRR 0.37 [95% CI 0.15–0.91]; P = 0.03), but there were no significant differences in other secondary outcomes between groups: ED presentations, hospitalisations or falls risk, falls efficacy, and quality of life. There were two deaths in the RESPOND group and one in the control group. No adverse events or unintended harm were reported. Limitations of this study were the high number of dropouts (n = 93); possible underreporting of falls, fall injuries, and hospitalisations across both groups; and the relatively small number of fracture events.ConclusionsIn this study, providing a telephone-based, patient-centred falls prevention program reduced falls but not fall injuries, in older people presenting to the ED with a fall. Among secondary outcomes, only fractures reduced. Adopting patient-centred strategies into routine clinical practice for falls prevention could offer an opportunity to improve outcomes and reduce falls in patients attending the ED.Trial registrationAustralian New Zealand Clinical Trials Registry (ACTRN12614000336684).

Perspectives of English, Chinese, and Spanish-Speaking Safety-Net Patients on Clinician Computer Use: Qualitative Analysis.

BackgroundSafety-net systems serve patients with limited health literacy and limited English proficiency (LEP) who face communication barriers. However, little is known about how diverse safety-net patients feel about increasing clinician electronic health record (EHR) use.ObjectiveThe aim of this study was to better understand how safety-net patients, including those with LEP, view clinician EHR use.MethodsWe conducted focus groups in English, Spanish, and Cantonese (N=37) to elicit patient perspectives on how clinicians use EHRs during clinic visits. Using a grounded theory approach, we coded transcripts to identify key themes.ResultsAcross multiple language groups, participants accepted multitasking and silent clinician EHR use if focused on their care. However, participants desired more screen share and eye contact, especially when demonstrating physical concerns. All participants, including LEP participants, wanted clinicians to include them in EHR use.ConclusionsLinguistically diverse patients accept the value of EHR use during outpatient visits but desire more eye contact, verbal warnings before EHR use, and screen-sharing. Safety-net health systems should support clinicians in completing EHR-related tasks during the visit using patient-centered strategies for all patients.

Tailor-Made Hand Exoskeletons at the University of Florence: From Kinematics to Mechatronic Design

Recently, robotics has increasingly become a companion for the human being and assisting physically impaired people with robotic devices is showing encouraging signs regarding the application of this largely investigated technology to the clinical field. As of today, however, exoskeleton design can still be considered a hurdle task and, even in modern robotics, aiding those patients who have lost or injured their limbs is surely one of the most challenging goal. In this framework, the research activity carried out by the Department of Industrial Engineering of the University of Florence concentrated on the development of portable, wearable and highly customizable hand exoskeletons to aid patients suffering from hand disabilities, and on the definition of patient-centered design strategies to tailor-made devices specifically developed on the different users’ needs. Three hand exoskeletons versions will be presented in this paper proving the major taken steps in mechanical designing and controlling a compact and lightweight solution. The performance of the resulting systems has been tested in a real-use scenario. The obtained results have been satisfying, indicating that the derived solutions may constitute a valid alternative to existing hand exoskeletons so far studied in the rehabilitation and assistance fields.

Sex differences in knee extension rate of torque development and patient-reported function among individuals with anterior cruciate ligament reconstruction

Purpose: Men and women with anterior cruciate ligament reconstruction (ACLR) continue to receive similar rehabilitative care despite evidence that women are more likely to experience poor clinical outcomes, a more than 4 times greater risk for second ACL injury, and a 45% greater risk of developing post-traumatic osteoarthritis (PTOA) when compared to men of similar age and activity level. While the mechanism of PTOA development following ACLR remains unclear, altered knee joint loading characteristics during activities of daily living have been hypothesized as potential contributors to the early stages of this process. Recently, knee extension strength, knee extension rate of torque development (RTD), and patient-reported psychological readiness have been shown to influence lower extremity loading characteristics, but it remains unclear if sex differences are present in these outcome measures. If present, this would help to explain the disparate outcomes experienced by men and women with ACLR. Identification of modifiable outcomes such as knee extension strength characteristics and psychological readiness early after ACLR may provide clinicians with feasible targets for patient-centered intervention within this population. Therefore, the primary purpose of this study was to determine the effect of participant sex on measures of knee extension strength characteristics and psychological readiness among men and women within the first year after ACLR. Methods: Thirty-three women (age= 19.0±4.3 years, time since surgery= 6.8±1.6 months) and 29 men (age= 21.4±6.8 years, time since surgery= 7.4±2.3 months) with a history of ACLR were enrolled in an on-going cohort study from which these data were obtained. Participants were included if they were between the ages of 13 and 40, had a history of ACLR, were within 2 weeks of their final clinical visit to their orthopaedic surgeon, and had not yet returned to sport participation. Participants completed a detailed health history, the ACL Return to Sport After Injury (ACL-RSI) scale, and the International Knee Documentation Committee (IKDC) subjective knee evaluation form after which they performed a bilateral assessment of knee extension maximal voluntary isometric contraction (MVIC) strength using a multimodal dynamometer. After a standardized familiarization protocol, participants completed 3 knee extension MVIC trials during which they were instructed to “kick out as hard and fast as possible” while being provided visual feedback on a nearby monitor. Peak knee extension MVIC torque (Nm) was documented from each trial and normalized to body mass (Nm/kg). Additionally, RTD100 was calculated as the slope of the torque x time curve from contraction initiation to 100ms following contraction initiation (Nm*kg-1*s-1) and RTD200 was calculated as the slope from of the torque x time curve from 100ms to 200ms after contraction initiation (Nm*kg-1*s-1). Participant demographics were compared between the sexes using independent samples t-tests while patient-reported outcome measures and knee extension strength characteristics were compared using ANCOVA with months since surgery as a covariate. Results: There were no significant sex differences in age (p= 0.10), time since surgery (p=0.65), patient-reported knee function (Female= 80.9±11.2, Male= 85.1±9.2; p= 0.11), or psychological readiness for sport (Female= 69.3±23.8, Male= 62.8±24.5; p= 0.25) among participants with ACLR. Female participants displayed lesser involved limb (Female= 1.99±0.53 Nm/kg, Male= 2.71±0.71 Nm/kg; p < 0.001) and contralateral limb (Female= 2.62±0.59 Nm/kg, 3.17±0.52 Nm/kg; p < 0.001) knee extension MVIC torque as well as lesser involved limb knee extension RTD100 (Female= 6.41±2.39 Nm*kg-1*s-1, Male= 8.24±3.17 Nm*kg-1*s-1; p= 0.01) and involved limb RTD200 (Female= 6.62±2.21 Nm*kg-1*s-1, Male= 9.43±3.40 Nm*kg-1*s-1; p < 0.001; Figure 1) when compared to male participants. Conclusions: Our findings indicate that women experience larger magnitude deficits in involved limb knee extension strength and RTD when compared to men during the terminal phase of clinical care following ACLR. This is despite no significant differences in patient-reported knee function or psychological readiness between the sexes. While not perceived as a functional limitation among women with ACLR, persistent quadriceps dysfunction and the associated alterations in lower extremity loading characteristics may set the stage for early degenerative changes in knee joint articular cartilage structure. Early identification of sex-based disparities in modifiable functional outcomes (knee extension strength and RTD) following ACLR may provide clinicians with goals for patient-centered impairment-based rehabilitation strategies to improve lower extremity loading characteristics which are implicated in the early progression of PTOA.

Sleepless nights and sleepy days: a qualitative study exploring the experiences of patients with chronic heart failure and newly verified sleep-disordered breathing.

Sleep-disordered breathing, including obstructive sleep apnoea and central sleep apnoea, is a common disorder among patients with chronic heart failure. Obstructive sleep apnoea is often treated with continuous positive airway pressure, but central sleep apnoea lacks a clear treatment option. Knowledge of how sleep-disordered breathing is experienced (e.g. difficulties and careneeds) and handled (e.g. self-care actions) by the patients is limited, but needed, to provide patient-centred care. To explore how newly verified sleep-disordered breathing is experienced by patients with chronic heart failure. Data were collected through semi-structured interviews and analysed with qualitative content analysis. Seventeen participants (14 men, three women), mean age 60years (range 41-80) diagnosed with chronic heart failure and objectively verified sleep-disordered breathing (nine obstructive, seven central and one mixed) were strategically selected from heart failure outpatient clinics at two Norwegian university hospitals. Patients with chronic heart failure and newly verified sleep-disordered breathing (SDB) described experiences of poor sleep that had consequences for their daily life and their partners. Different self-care strategies were revealed, but they were based on 'common sense' and were not evidence-based. The awareness of having SDB was varied; for some, it gave an explanation to their trouble while others were surprised by the finding. Patients with chronic heart failure and sleep-disordered breathing experienced reduced sleep quality, influencing their daily life. Possible underlying causes of disrupted sleep, such as sleep-disordered breathing, should be identified to establish proper patient-centred treatment strategies. There is a need for new strategies to approach patients with chronic heart failure (i.e. those with central sleep apnoea) who are not subject to continuous positive airway pressure treatment for their sleep-disordered breathing.

Older adults' suggestions to engage other older adults in health and healthcare: a qualitative study conducted in western Canada.

AimThis qualitative study reports identified themes from suggestions made by 533 Canadian older adults, aged ≥65 years in response to the open-ended question contained in a Saskatchewan Telephone Survey: “What suggestions can you make to engage someone in their health and healthcare?”.BackgroundIn 2016, seniors accounted for 16.9% of the Canadian population. As Canadians age over the next 30 years, emergency room visits are predicted to increase by 40%, outpacing the expected 30% population growth. Avoiding this increase could save the nation about $210 million annually. A recent US study reported that the ability of seniors to carry out self-care actions predicted lower likelihood of emergency department use within 3 months.Materials and methodsWe conducted a secondary data analysis based on a province-wide, cross-sectional Saskatchewan (Canada) Telephone Survey of seniors’ self-care needs conducted in March–June 2018 (N=1,000). Results were analyzed using qualitative thematic content analysis. Data were charted and coded separately by two researchers; coding conflicts were resolved by consensus.ResultsA total of 533 seniors answered the open-ended question. Content analysis resulted in 11 contextual content areas with 956 total suggestions. Five key themes emerged, which included the following: feasible healthcare access, being proactive toward healthy living, having social support systems, being more open to alternative medicine, and other self-care options, and having more trained healthcare professionals to care for seniors.ConclusionThis study reveals facilitators and challenges that currently face seniors. Seniors want equitable access to professional healthcare services and an environment that fosters self-care actions in everyday living. There is a gap in supports that would assist seniors to engage in their health and healthcare. Additional research on this issue could further inform health and human service providers to develop patient-centered strategies for promoting self-care among seniors.

A feasibility study of a patient-centered educational strategy for rampant inhaler misuse among minority children with asthma

A feasibility study of a patient-centered educational strategy for rampant inhaler misuse among minority children with asthma

The importance of dialogue: communication strategy for empowerment of low-income African American patients via in-depth interviews of primary care providers at inner-city health clinics

ABSTRACT Purpose: We explored how primary care providers perceive their interactions with low-income African American patients at two inner-city health clinics. Background: Drawing from theories of empowerment and community development, we asked what types of communication strategies health care providers consider crucial for creating/maintaining empowered low-income African American patients. Method: We conducted twelve in-depth interviews and performed data analysis to identify recurring themes and report them within the scope of the qualitative nature of the current data. Results: Healthcare providers reported that they are fully aware of and actively use the patient-centered/collaborative strategies identified in the literature. They expressed their desire/willingness to work with their patients as partners in patient health management/improvement rather than simply instructing them. They also prefer highly motivated patients to improve their own health outcomes. Conclusion: Overall findings suggest providers, working in inner-city health clinics, understand and use accommodating/collaborating and patient-centered strategies daily to empower their low-income African American patients.

Clinical care gaps and solutions in diabetes and advanced chronic kidney disease: a patient-oriented qualitative research study.

Patients with diabetes and advanced chronic kidney disease face a high health care burden. As part of a patient-oriented research initiative to identify ways to better support patients' diabetes care, we explored their health care experience and solutions for patient-centred diabetes care. We engaged 2 patients with advanced kidney disease and diabetes to join our multidisciplinary team as full research partners. They were involved in our design and conduct of the study, the analysis of the results and knowledge translation. We conducted qualitative interviews (1:1 semistructured interviews and focus groups) with patients with a history of both diabetes (type 1 or 2) and advanced kidney disease including those using dialysis. We identified overarching themes using individual and team analysis and conducted interviews until data saturation was reached. Twelve participants were interviewed between October 2017 and February 2018. Six people were interviewed in 2 separate focus groups (consisting of 4 and 2 participants) and 6 participated in 1:1 interviews with our team. Participants described being burdened by medical appointments, strict conflicting diets, costly diabetes therapies and fragmented, siloed health care. They indicated that self-management support, education and coordinated diabetes care might better support their diabetes care. Patients with complex medical comorbidities face many challenges traversing a health care system organized around single diseases. Researchers and policy-makers should study and develop patient-centred diabetes care strategies to better support these high-risk patients.

The empirical test of pharmacist-patient relationship model in hospital pharmacy practice: Indonesia context

Patient-centered care is an essential element that must be applied in various lines of services in hospitals to realizing patient safety, one of which is pharmaceutical services. This study aimed to examine the pharmacist patient relationships model in Indonesian hospitals. This research is a quantitative study and survey design were uses a cross sectional approach. The sampling were used purposive sampling method. The number of respondents was used of 432 outpatient. This study was carried out in four hospitals in Special Region of Yogyakarta. Data analysis was performed using linear multiple regression analysis. The results of hypothesis testing based on probability values (p<0.05) indicate that the pharmacist participative and interpersonal communication have a significant effect on relationship quality and patient satisfaction. However, patient participative there is no significant effect on relationship quality and patient satisfaction. The relationship quality has a significant effect on patient satisfaction and also mediates the relationship between pharmacist participative and interpersonal communication with patient satisfaction. The paradigm of pharmaceutical care was change from drug oriented to patient-oriented. The pharmacist has the right position to implement a patient-centered care strategy and solving medication-related problems. The interaction between pharmacists and patients is an effective learning in the application of patient-centered care.

Validation of the Computerized Adaptive Test for Mental Health in Primary Care.

The US Preventive Services Task Force recommends screening for depression in the general adult population. Although screening questionnaires for depression and anxiety exist in primary care settings, electronic health tools such as computerized adaptive tests based on item response theory can advance screening practices. This study evaluated the validity of the Computerized Adaptive Test for Mental Health (CAT-MH) for screening for major depressive disorder (MDD) and assessing MDD and anxiety severity among adult primary care patients. We approached 402 English-speaking adults for participation from a primary care clinic, of whom 271 adults (71% female, 65% black) participated. Participants completed modules from the CAT-MH (Computerized Adaptive Diagnostic Test for MDD, CAT-Depression Inventory, CAT-Anxiety Inventory); brief paper questionnaires (9-item Patient Health Questionnaire [PHQ-9], 2-item Patient Health Questionnaire [PHQ-2], Generalized Anxiety Disorder 7-item Scale [GAD-7]); and a reference-standard interview, the Structured Clinical Interview for DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) Diagnoses. On the basis of the interview, 31 participants met criteria for MDD and 29 met criteria for GAD. The diagnostic accuracy of the Computerized Adaptive Diagnostic Test for MDD (area under curve [AUC] = 0.85) was similar to that of the PHQ-9 (AUC = 0.84) and higher than that of the PHQ-2 (AUC = 0.76) for MDD screening. Using the interview as the reference standard, the accuracy of the CAT-Anxiety Inventory (AUC = 0.93) was similar to that of the GAD-7 (AUC = 0.97) for assessing anxiety severity. The patient-preferred screening method was assessment via tablet/computer with audio. Computerized adaptive testing could be a valid and efficient patient-centered screening strategy for depression and anxiety screening in primary care settings.

A Patient-Centered Multicomponent Strategy for Accelerated Linkage to Care Following Community-Wide HIV Testing in Rural Uganda and Kenya.

As countries move toward universal HIV treatment, many individuals fail to link to care after diagnosis of HIV. Efficient and effective linkage strategies are needed. We implemented a patient-centered, multicomponent linkage strategy in the SEARCH "test-and-treat" trial (NCT 01864603) in Kenya and Uganda. After population-based, community-wide HIV testing, eligible participants were (1) introduced to clinic staff after testing, (2) provided a telephone "hot-line" for enquiries, (3) provided an appointment reminder phone call, (4) given transport reimbursement on linkage, and (5) tracked if linkage appointment was missed. We estimated the proportion linked to care within 1 year and evaluated factors associated with linkage at 7, 30, and 365 days after diagnosis. Among 71,308 adults tested, 6811 (9.6%) were HIV-infected; of these, 4760 (69.9%) were already in HIV care, and 30.1% were not. Among 2051 not in care, 58% were female, median age was 32 (interquartile range 26-40) years, and median CD4 count was 493 (interquartile range 331-683) cells/µL. Half (49.7%) linked within 1 week, and 73.4% linked within 1 year. Individuals who were younger [15-34 vs. >35 years, adjusted Risk Ratio (aRR) 0.83, 95% confidence interval (CI): 0.74 to 0.94], tested at home vs. community campaign (aRR = 0.87, 95% CI: 0.81 to 0.94), had a high HIV-risk vs. low-risk occupation (aRR = 0.81, 95% CI: 0.75 to 0.88), and were wealthier (aRR 0.90, 95% CI: 0.83 to 0.97) were less likely to link. Linkage did not differ by marital status, stable residence, level of education, or having a phone contact. Using a multicomponent linkage strategy, high proportions of people living with HIV but not in care linked rapidly after HIV testing.

Impact of stratification on the effectiveness of a comprehensive patient-centered strategy for multimorbid patients.

The objective of this work was to assess the effectiveness of a population-level patient-centered intervention for multimorbid patients based on risk stratification for case finding in 2014 compared with the baseline scenario in 2012. Clinical and administrative databases. This was an observational cohort study with an intervention group and a historical control group. A propensity score by a genetic matching approach was used to minimize bias. Generalized linear models were used to analyze relationships among variables. We included all eligible patients at the beginning of the year and followed them until death or until the follow-up period concluded (end of the year). The control group (2012) totaled 3558 patients, and 4225 patients were in the intervention group (2014). A patient-centered strategy based on risk stratification for case finding and the implementation of an integrated program based on new professional roles and an extensive infrastructure of information and communication technologies avoided 9 percent (OR: 0.91, CI: 0.86-0.96) of hospitalizations. However, this effect was not found in nonprioritized groups whose probability of hospitalization increased (OR: 1.19, CI=1.09-1.30). In a before-and-after analysis using propensity score matching, a comprehensive, patient-centered, integrated care intervention was associated with a lower risk of hospital admission among prioritized patients, but not among patients who were not prioritized to receive the intervention.

Typology of patients with behavioral addictions or eating disorders during a one-year period of care: Exploring similarities of trajectory using growth mixture modeling coupled with latent class analysis

ObjectivesAddictions are not restricted to substance-use disorders, and it is now widely recognized that they also include behavioral addictions. Certain individuals with eating disorders also experiment their disorder as an addiction. The objective was to identify typologies of patients presenting with various behavioral addictions or eating disorders according to their evolution within the framework of care, and to specify the factors associated with the differential clinical trajectories.MethodsWe included 302 patients presenting with problem gambling, sexual addiction, compulsive buying, excessive videogame use or eating disorders. The patients completed a multiaxial assessment through a face-to-face structured interview and self-administered questionnaires, including sociodemographic and addiction-related characteristics, psychiatric and addictive comorbidities and several psychological characteristics. The assessment was performed at inclusion and then repeated after 6 and 12 months. The statistical analysis included a combination of growth mixture models and latent class analysis.ResultsWe identified five classes of patients with different profiles related to their trajectories during a one-year period of specialized care: “complex patients”, “patients with impulsive psychological functioning”, “patients with cooperative psychological functioning”, “patients with immature psychological functioning,” and “patients with resilient psychological functioning”.ConclusionsThe typology obtained brings interesting findings to propose patient-centered care strategies adapted to these disorders. Because the typology was independent from the type of disorder, it supports the general concept of behavioral addictions, and the similarities between eating disorders and behavioral addictions. The relevance of this model should be further examined in future studies.

Elevated risk of viral rebound on ART in migrants living in France: role of socioeconomic factors.

In Western countries, viral rebound on antiretroviral therapy (ART) appears to occur more frequently in migrants. We aimed to assess the respective roles of socioeconomic factors and migration on viral rebound in people living with HIV (PLHIV) in France. We included PLHIV in France, enrolled from 2004 to 2008 in the French ANRS-COPANA cohort, who started a first ART and achieved undetectability (<50 copies/ml) within 1 year. Determinants of viral rebound were assessed using Cox models including geographical origin, HIV transmission group, and clinicobiological and sociodemographic data. Of 499 included individuals, 288 were born in France, 158 in sub-Saharan Africa (SSA) and 53 in another country. Kaplan-Meier probabilities of viral rebound-free survival were similar for men having sex with men (MSM) and heterosexuals born in France, and lower in migrants from SSA or other countries (P<0.001). The crude hazard ratio (HR) of viral rebound was 2.49 (95% CI, 1.59, 3.90) in migrants from SSA and 1.78 (0.94, 3.88) in migrants from other countries compared with MSM born in France. Educational level, financial difficulties and HIV status disclosure had the biggest impact on the difference between the crude and adjusted HRs for viral rebound in migrants. In multivariable analysis, viral rebound was no longer associated with geographical origin, but with protease inhibitor-containing ART, a VACS index ≥35 as a potential indicator of frailty, poor financial status (difficulties or debts) and non-disclosure to friend(s). Socioeconomic factors affect outcomes on ART, even in the context of free access to HIV care and treatment. Patient-centred strategies should be encouraged with the intervention of social workers to address basic needs and promote social support for more socially vulnerable individuals.