The challenge of referring HIV-positive pregnant women with treatment indication from PMTCT to ART services: a retrospective follow-up study in Mbeya,Tanzania

Providing full antiretroviral therapy (ART) to all HIV-positive, pregnant women with treatment indication could significantly reduce overall mother-to-child transmission. However, the effectiveness of referring HIV-positive antenatal care (ANC) clients with a treatment indication to ART services has rarely been assessed to date. We retrospectively followed-up data of a cohort of treatment-eligible ANC clients in Mbeya Region, Tanzania by retracing and merging registries of ANC, Care and Treatment Centers (CTC), and Infant Care. ART initiation and ART duration before delivery served as primary outcome indicators to assess referral effectiveness. We retraced data of 60 ANC clients with treatment indication: 39 (65%) started predelivery ART and 21 (35%) remained untreated during pregnancy. Eight (13.3%) did not initiate ART at all within the observation period. Women starting ART before delivery had significantly lower CD4-cell counts at enrollment than nonstarters (medians: 207.5 vs. 292 cells/µl; p = 0.013). Predelivery ART starters had experienced a significantly shorter duration between staff-declared “ART readiness” and actual ART start (medians: 0 vs. 28 days; p = 0.0004). The median ART duration prior to delivery was 57 days; only eight women (13.3%) accomplished ≥90 days ART intake during pregnancy. Early enrollment in ANC at ≤24 gestational weeks was associated with longer duration of predelivery ART. At maternity wards, 24.3% of treatment-eligible mothers and newborns with retraceable delivery data had received no or inadequate antiretrovirals. Within 6 months postdelivery, women attended on average 3.5 out of 6 requested CTC visits. Concluding, every third treatment-eligible woman in this cohort was not covered through ART before delivery, and predelivery ART duration was mostly suboptimal regarding vertical transmission prevention. HIV-positive women need to be encouraged to approach ANC early in pregnancy, and health services need to address unnecessary time gaps before ART initiation. In addition, inclusive ART services for HIV-positive ANC clients should be seriously discussed.     

Adjuvant chemotherapy after resection of N1 non-small cell lung cancer: differential impact of new evidence on physician and patient decisions

Background

Adjuvant cisplatin-based chemotherapy (ACT) after resection of stages II-IIIA non-small cell lung cancer (NSCLC) modestly increased survival in several clinical trials. This study evaluated the subsequent impact of those trials on ACT use in clinical practice.

Methods

Patients who underwent lobectomy or more extensive lung resection without induction chemotherapy for pathologically confirmed N1 positive NSCLC between 2000 and 2012 were reviewed. Referrals to medical oncology, oncologist recommendations for ACT, and initiation of ACT were evaluated. Because major trials supporting ACT were published in 2004 and 2005, analysis was stratified into two eras: 2000-2005 and 2006-2012.

Results

During the study period, 272 patients met inclusion criteria (110 in the 2000-2005 cohort, 162 in the 2006-2012 cohort). Referrals to medical oncology increased from 74.5% (n=82) in the 2000-2005 cohort to 90.1% (n=146) in the 2006-2012 cohort (P=0.002). Due to lack of referral or missed appointments, 35.5% (n=39) of the 2000-2005 patients and 17.9% (n=32) of the 2006-2012 patients did not have a documented conversation with an oncologist regarding ACT. The proportion of patients recommended for ACT increased from 61% (n=50) to 81.5% (n=119) between the eras (P<0.001). Of patients recommended for chemotherapy, 14% (7/50) in 2000-2005 and 13.4% (16/119) in 2006-2012 declined ACT (P=0.666).

Conclusions

Publication of supporting evidence increased recommendations for ACT but did not change the percentage of patients who ultimately agreed to receive ACT. Additional research is needed to better understand patient decision-making in this situation.     

A Web-based Generalist–Specialist System to Improve Scheduling of Outpatient Specialty Consultations in an Academic Center

BACKGROUND  Failed referrals for specialty care are common and often represent medical errors. Technological structures and processes account for many failures. Scheduling appointments for subspecialty evaluation is a first step in outpatient referral and consultation. OBJECTIVE  We determined whether moving from paper-based referrals to a Web-based system with automated tracking features was associated with greater scheduling of appointments among referred patients. DESIGN  Staggered implementation of a quality-improvement project, with comparison of intervention and control groups. PARTICIPANTS  Patients 21 or more years of age referred from any of 11 primary-care clinics to any of 25 specialty clinics. INTERVENTIONS  Faxed referrals were replaced by a Web-based application shared by generalists and specialists, with enhanced communications and automated notification to the specialty office. MEASUREMENTS  We compared scheduling before and after implementation and time from referral to appointment. A logistic regression analysis adjusted for demographics. MAIN RESULTS  Among 40,487 referrals, 54% led to scheduled specialty visits before intervention, compared to 83% with intervention. The median time to appointment was 168 days without intervention and 78 days with intervention. Scheduling increased more when duplicate referrals were not generated (54% for single orders, 24% for multiple orders). After adjustment, referrals with the intervention were more than twice as likely to have scheduled visits. CONCLUSIONS  With a new Web-based referrals system, referrals were more than twice as likely to lead to a scheduled visit. This system improves access to specialty medical services. SUPPORT:  Dr. Weiner was supported by grant number 5K23AG020088 from the National Institute on Aging. This study was supported by Wishard Health Services, Indianapolis, Indiana.     

Evaluation of the learning outcomes of a year-long postgraduate training course in community geriatrics for primary care doctors

There are increasing expectations on primary care doctors to shoulder a bigger share of care for patients with common geriatric problems in the community. This study aims to examine the outcomes of a postgraduate training course in geriatrics for primary care doctors. A questionnaire developed by the research team was sent to the course graduates (years 2001-2007). Ninety-eight replies were received with a response rate of 52.4% (98/187). Difference in the ratings by the respondents before and after taking the course was analyzed using the nonparametric Wilcoxon signed rank test. Most respondents felt more rewarding and had participated more in geriatric care, and the majority had improvement in their communication skills with elderly patients after taking the course. Moreover, the graduates are more confident in diagnosing and managing common geriatric problems, and deciding to which specialty to refer the elderly patients. Of the referrals, there was a significant increase to private geriatricians and a significant reduction to other specialists. The average number of elderly patients seen per day had also increased. However, little change was observed about making nursing home visits, the frequency of which remained low. Many graduates expressed difficulties in conducting nursing home visits.     

Ancillary service needs among persons new to HIV care and the relationship between needs and late presentation to care

Ancillary service needs likely influence time to diagnosis and presentation for HIV care. The effect of both met and unmet needs on late presentation to HIV care is not well understood. We used baseline data from 348 people with HIV (PWH) with no prior HIV care who enrolled in iENGAGE (a randomized controlled trial (RCT) of an intervention to support retention in care) at one of four HIV clinics in the US. A standardized baseline questionnaire collected information on ancillary service needs, and whether each need was presently unmet. We examined covariates known to be associated with disease stage at presentation to care and their association with needs. We subsequently assessed the relationship of needs with CD4 accounting for those other covariates by estimating prevalence ratios (PR) using inverse probability weights. Most patients enrolling in the RCT were male (79%) and the majority were Black (62%); median age was 34 years. Prevalence of any reported individual need was 69%. One-third of the sample had a baseline CD4 cell count <200, 42% between 200 and 499 and 27% ≥500. There was no statistically significant association between need or unmet need and baseline CD4. In general, psychiatric health and SU issues (depression, anxiety, and drug use) were consistently associated with higher prevalence of need (met and unmet). Additionally, the Black race was associated with higher basic resource needs (housing: PR 1.67, 95%CI 1.08–2.59; transportation: PR 1.65, 95% CI 1.12–2.45). Ancillary service needs (met and unmet) were common among patients new to HIV care and impacted vulnerable subgroups. However, we found no evidence that reporting a specific individual need, whether met or unmet, was associated with a timely presentation to HIV care. The impact of needs on subsequent steps of the HIV care continuum will be examined with longitudinal data.     

Patients as teachers: a new approach to patient involvement

Patients as Teachers is an approach to patient involvement which involves bringing together a key sub-group for a speciality with a facilitator to focus on particular aspects of the service. This approach was used by the rheumatology team in Bradford to elicit feedback from South Asian women for whom English is not the first language. The focus groups generated constructive feedback about issues relating to, the hospital environment, information giving and service provision. This was fed back to clinicians at an educational meeting attended by lay representatives, and agreed actions were determined. Progress made on the recommendations was evaluated at six months.     

A new era of amyloidosis: the trends at a major US referral centre

Abstract

Objective: To characterize the changing spectrum of amyloidosis classes, as well as patient demographics, at a major US referral centre.

Patients and methods: A retrospective analysis was conducted of all referrals to the Amyloidosis Centre at Boston University and Boston Medical Centre over the last 3 decades.

Results: A total of 3987 new patients with amyloidosis were evaluated between 1990 and 2018 with the average number of new cases per year increasing 2.5-fold during this period. Systemic immunoglobulin light-chain (AL) amyloidosis decreased in proportion with each decade from 77% to 69% to 50% of new cases. Meanwhile, ATTR amyloidosis increased from 12% to 16% to 29%, predominately due to more diagnosis of ATTRwt and ATTRV122I amyloidosis. Gender and race profile differences, while changing over the observed time period, persisted among amyloidosis patients.

Conclusion: Amyloid diseases are more widely recognized and classes of amyloidosis, including ATTRwt and ATTRV122I, once considered rare are now increasingly diagnosed. These data likely reflect a national trend of increased amyloidosis awareness facilitated by accessible diagnostic approaches, emerging treatments, and coordinated educational initiatives.

Trial registration: ClinicalTrials.gov identifier: NCT00898235.     

Ancillary referral patterns in infants after initial assessment in a cardiac developmental outcomes clinic

Objective: Neurodevelopmental impairment is common after surgery for congeni‐ tal heart disease (CHD) in infancy. While neurodevelopmental follow‐up of high‐risk patients has increased, the referral patterns for ancillary services following initial evaluation have not been reported. The aim of this study is to describe the rates and patterns of referral at the initial visit to our outcomes clinic of patients who under‐ went surgery for CHD during infancy.
Outcomes Measures: The Cardiac Developmental Outcomes Program clinic at Texas Children’s Hospital provides routine longitudinal follow‐up with developmental pedi‐ atricians and child psychologists for children who required surgery for CHD within the first 3 months of life. Demographic, diagnostic, and clinical data, including prior receipt of intervention and referral patterns at initial presentation, were abstracted from our database.
Results: Between April 2013 and May 2017, 244 infants under 12 months of age presented for initial evaluation at a mean age of 7 ± 1.3 months. At presentation, 31% (76/244) were referred for either therapeutic intervention (early intervention or pri‐ vate therapies), ancillary medical services, or both. Referral rates for low‐risk (STAT 1‐3) and high‐risk (STAT 4‐5) infants were similar (28 vs. 33%, P = .48). Referrals were more common in: Hispanic white infants (P = .012), infants with non‐cardiac congeni‐ tal anomalies (P = .001), history of gastrostomy tube placement (P < .001), and infants with prior therapy (P = .043). Infants of non‐English speaking parents were three times more likely to be referred (95% CI = 1.5, 6.4; P = .002).
Conclusion: At the time of presentation, nearly 1 in 3 infants required referral. Referral patterns did not vary by traditional risk stratification. Sociodemographic fac‐ tors and co‐morbid medical conditions increased the likelihood of referral. This sup‐ ports the need for routine follow‐up for all post‐surgical infants regardless of level of surgical complexity. Further research into the completion of referrals and long‐term referral patterns is needed.     

Alcohol marketing research: the need for a new agenda

Aims This paper aims to contribute to a rethink of marketing research priorities to address policy makers' evidence needs in relation to alcohol marketing. Method Discussion paper reviewing evidence gaps identified during an appraisal of policy options to restrict alcohol marketing. Findings Evidence requirements can be categorized as follows: (i) the size of marketing effects for the whole population and for policy‐relevant population subgroups, (ii) the balance between immediate and long‐term effects and the time lag, duration and cumulative build‐up of effects and (iii) comparative effects of partial versus comprehensive marketing restrictions on consumption and harm. These knowledge gaps impede the appraisal and evaluation of existing and new interventions, because without understanding the size and timing of expected effects, researchers may choose inadequate time‐frames, samples or sample sizes. To date, research has tended to rely on simplified models of marketing and has focused disproportionately on youth populations. The effects of cumulative exposure across multiple marketing channels, targeting of messages at certain population groups and indirect effects of advertising on consumption remain unclear. Conclusion It is essential that studies into marketing effect sizes are geared towards informing policy decision‐makers, anchored strongly in theory, use measures of effect that are well‐justified and recognize fully the complexities of alcohol marketing efforts.