A package of primary health care services for comprehensive family-centred HIV/AIDS care and treatment programs in low-income settings

Particularly in resource-limited settings, HIV/AIDS is a family concern. Separate services for children and adults may make accessing care more difficult for families than services where family members can be cared for together. Implicit in comprehensive, family-centred approaches to care are the broader notions of longitudinal primary care and linkages to other services, including those based in communities. As highly-active antiretroviral therapy becomes more available, and the direct burden of HIV-associated morbidity diminishes, HIV-infected individuals require primary care that goes beyond exclusive management of HIV and related conditions, including preventive services and the management of common medical issues. The prevention of tuberculosis, diarrhoea, and, in endemic regions, malaria; the addressing of debilitating depression; cervical screening; and the management of chronic cardiovascular disease and its risk factors are all of benefit to patients accessing HIV/AIDS care. Packaging such services is an effective means both of standardizing care within a program and of ensuring patients receives a full roster of available interventions. As family-centred care models develop in resource-limited settings, the availability of evidence-based service packages such as presented here will help program designers prioritize available human and materiel resources toward those interventions that improve patients' global health and well being.     

Sustaining HIV prevention: HIV testing in health care settings

The Centers for Disease Control and Prevention (CDC) recently issued revised HIV testing recommendations, including a recommendation for routine, voluntary screening for all persons aged 13 years to 64 years in health care settings. Screening is not based on risk, and prevention counseling in conjunction with HIV testing in health care settings is not required. The revisions were motivated in part by concerns regarding the substantial undiagnosed fraction of prevalent HIV infections in the United States and evidence awareness of HIV infection leads to substantial reductions in high-risk sexual behavior. It is hoped that implementation of these recommendations, which will require coordination and education initiatives, will increase identification of the large number of HIV-infected individuals unaware of their infection status and facilitate their linkage to care. This article summarizes a presentation on HIV prevention and HIV testing in health care settings made by Kevin A. Fenton, MD, PhD, at the 10th Annual Ryan White HIV/AIDS Program Clinical Update in June 2007 in Phoenix, AZ.     

The growth of business firms: theoretical framework and empirical evidence

We introduce a model of proportional growth to explain the distribution P(g)(g) of business-firm growth rates. The model predicts that P(g)(g) is exponential in the central part and depicts an asymptotic power-law behavior in the tails with an exponent zeta = 3. Because of data limitations, previous studies in this field have been focusing exclusively on the Laplace shape of the body of the distribution. In this article, we test the model at different levels of aggregation in the economy, from products to firms to countries, and we find that the predictions of the model agree with empirical growth distributions and size-variance relationships.     

Evidence, research, and clinical practice: a patient-centered framework for progress in wound care

Traditional criteria used in selecting wound care interventions are being slowly replaced with an evidence-based practice approach. The value of such an approach for providing optimal care has been established, but the definition of evidence- based care and the process used to generate evidence continue to evolve. For example, the role of studies developed to demonstrate efficacy, randomized controlled trials (RCT), the value of effectiveness studies designed to evaluate outcomes in real world practice, and the use of disease-oriented (interim) study outcomes for wound care research such as reduces wound fluid or improves granulation tissue formation have been topics of international conversations and consensus documents. In addition, the use in some clinical studies and most systematic study reviews of ingredient- or characteristic-based categories to group products that may not share a common operational definition of how they function has led to a high variability in outcomes, resulting in inconclusive or low-level evidence. These concerns and debates, along with their influence on practice, may cast doubt on the value of evidence-based practice guidelines for some clinicians, slowing their rate of implementation and extending the discussion about definitions of evidence-based care and the relative merits of various research designs. At the same time, amid growing concerns about medical device safety, clinicians must answer three questions about an intervention and its related products or devices in order to provide safe and effective care: 1) Can it work? 2) Does it work? 3) Is it worth it? Reviewing current knowledge about wound care, wound treatment modalities, and the basic principles of research within the existing framework of questions to be answered suggests a clear path toward obtaining much-needed evidence. In wound care, using clearly defined process- es to study patient-centered outcomes (eg, quality of life, complete healing) and only product groupings that meet an operational definition of functioning (eg moisture-retentive) will help clinicians decide whether an intervention can work and does work and whether the value of the clinical and economic benefits is greater than the potential harm and cost.     

Nature of community pharmacy in home care

To analyze the reason why home care service which community pharmacists provide has not been effectively utilized, a questionnaire on home care services was submitted to 472 home care service users, 215 general practitioners, 10 visiting nurses and 153 home-helpers, and 75 community pharmacists. We were interested in whether or not gaps existed between users' needs, practitioners' demands, and pharmacists' awareness of professional responsibility to pharmacy services. Also, we were interested in whether or not gaps existed in awareness of the importance of cooperation with community pharmacists and influencing factors between practitioners and home-helpers and visiting nurses. The main results were as follows: users and practitioners considered that counseling about home care and welfare services by community pharmacists was important and home visiting was not so important. However, pharmacists considered that home visiting was important and counseling about home care and welfare services was not so important. Therefore, gaps existed between users' needs, practitioners' demands, and pharmacists' awareness of professional responsibility to pharmacy services. Practitioners' awareness of the importance of cooperation with community pharmacists in comparison to that of other professionals was low as well as that of home-helpers, and visiting nurses. However, over 70% of them recognized the necessity of home visiting services by pharmacists. As far as factors influencing the awareness of the importance of cooperation with community pharmacists, practitioners' recognition to home visiting by pharmacists was higher than that of home-helpers and visiting nurses. However, expectations regarding community pharmacists' participation in home care services was higher than that of practitioners.     

Strategies to enhance linkages between care for HIV/AIDS in jail and community settings

The policies of mass incarceration and the expansion of the criminal justice system in the USA over the last 40 years have weighed heavily on individuals and communities impacted by drug use and HIV disease. Though less than ideal, jails provide a unique opportunity to diagnose, treat and implement effective interventions. The role of jails in HIV detection, treatment, and continuity of care, however, has yet to be systematically examined. This paper reviews the service strategies and contexts for 10 demonstration sites funded to develop innovative methods for providing care and treatment to HIV-infected individuals in jail settings who are returning to their communities. The sites have implemented varied intervention strategies; each set in unique policy and service system contexts. Collaboration among agencies and between systems to implement these interventions is viewed as particularly challenging undertakings. We anticipate the sites will collectively serve 700-1000 individuals across the duration of the initiative. In this paper, we review the service contexts and strategies developed by the 10 sites. The individual and multi-site evaluations aim to provide new data on testing, treatment, and community linkages from jails that will further develop our knowledge base on effective intervention strategies in these settings.     

The patient-driven payment model: A missed opportunity for patient-centered cancer care

Hospitalized older patients with advanced cancer who were discharged to a skilled nursing facility (SNF) for rehabilitation are unlikely to receive future cancer treatment, have high 30-day readmission rates, and high mortality yet minimal hospice use. The Medicare SNF benefit was designed to be a bridge and provide short-term nursing and rehabilitation care for patients after a hospitalization. However, advanced cancer patients churn through the health system cycling between the hospital, post-acute care facilities, and home in the last months of life. This article explores the potential impact of the patient-driven payment model, a new SNF reimbursement model introduced by the Center for Medicare and Medicaid Services in 2019, on the experience of older cancer patients. Previously, SNF reimbursement was based on the hours of rehabilitative therapy provided to patients, unintentionally incentivizing SNFs to provide more therapy resulting in long lengths of stay and increased Medicare expenditure. The new patient-driven payment model bases reimbursement on patient clinical characteristics and resources utilized during their SNF stay. We discuss the impact this payment model might have on cancer patients in the SNF setting and highlight the importance of access to palliative care for this population. We discuss challenges policymakers face in creating palliative care guidelines and developing palliative care delivery models in SNFs. We highlight the policy gaps that remain in creating a system that achieves high-quality SNF care and conclude by offering suggestions that might better incorporate a patient's illness trajectory, prognosis, and goals of care.     

Postural stability in the elderly: empirical confirmation of a theoretical model

The study investigated whether physiological factors related to specific body systems can explain postural control as measured by the scalar distance at a given time between the center of pressure (COP) and the center of mass (COM), the COP-COM variable. The data from 46 healthy subjects and 29 subjects with disabilities due to stroke or diabetic peripheral neuropathy were analyzed. The biomechanical variable COP-COM was determined using two force platforms and an optoelectric system. Three systems were considered as possible predictors of the COP-COM amplitude: sensory (somatosensory and vision), musculoskeletal and central processor. A confirmatory analysis was done using structural equation modeling. Strength explained 23.74% of the COP-COM amplitude in the antero-posterior (A/P) with eyes open (EO) condition, and in the medio-lateral (M/L) direction strength explained 40.73 and 28.75% in the EO and eyes closed (EC) respectively. In the A/P direction with EC, 51.75% of the COP-COM amplitude variance was explained mainly by the somatosensory system. This study highlight the role of peripheral somatosensory input and muscle strength in the maintenance of postural stability during quiet stance in the elderly. The indirect action of the different systems on the COP-COM amplitude supports the systems theory.     

Linear regression calibration: theoretical framework and empirical results in EPIC, Germany

Large scale dietary assessment instruments are usually based on the food frequency technique and have therefore to be tailored to the involved populations with respect to mode of application and inquired food items. In multicenter studies with different populations, the direct comparability of dietary data is therefore a challenge because each local dietary assessment tool might have its specific measurement error. Thus, for risk analysis the direct use of dietary measurements across centers requires a common reference. For example, in the European prospective cohort study EPIC (European Prospective Investigation into Cancer and Nutrition) a 24-hour recall was chosen to serve as such a reference instrument which was based on a highly standardized computer-assisted interview (EPIC-SOFT). The 24-hour recall was applied to a representative subset of EPIC participants in all centers. The theoretical framework of combining multicenter dietary information was previously published in several papers and is called linear regression calibration. It is based on a linear regression of the food frequency questionnaire to the reference. The regression coefficients describe the absolute and proportional scaling bias of the questionnaire with the 24-hour recall taken as reference. This article describes the statistical basis of the calibration approach and presents first empirical results of its application to fruit, cereals and meat consumption in EPIC Germany represented by the two EPIC centers, Heidelberg and Potsdam. It was found that fruit could be measured well by the questionnaire in both centers (lambdacirc; = 0.98 (males) and lambdacirc; = 0.95 (females) in Heidelberg, and lambdacirc; = 0.86 (males) and lambdacirc; = 0.7 (females) in Potsdam), cereals less (lambdacirc; = 0.53 (males) and lambdacirc; = 0.4 (females) in Heidelberg, and lambdacirc; = 0.53 (males) and lambdacirc; = 0.44 (females) in Potsdam), and that the assessment of meat (lambdacirc; = 0.72 (males) and lambdacirc; = 0.65 (females) in Heidelberg, and lambdacirc; = 0.49 (males) and lambdacirc; = 0.42 (females) in Potsdam) has a center-specific bias. The application of the calibration approach to the questionnaire data will change the ranking of the two centers following the data of the reference instrument, and not well-measured food items will exhibit considerably less variation compared to the original data. We conclude that calibration is a necessary step in multicenter studies. However, this exercise shows that the current statistical framework is not yet sufficiently developed for a broad application.     

Using the theoretical domains framework to identify barriers and enablers to pediatric asthma management in primary care settings

Objectives: This study aimed to apply a theory-based approach to identify barriers and enablers to implementing the Alberta Primary Care Asthma Pediatric Pathway (PCAPP) into clinical practice. Phase 1 included an assessment of assumptions underlying the intervention from the perspectives of the developers. Phase 2 determined the perceived barriers and enablers for: 1) primary care physicians' prescribing practices, 2) allied health care professionals' provision of asthma education to parents, and 3) children and parents' adherence to their treatment plans. Methods: Interviews were conducted with 35 individuals who reside in Alberta, Canada. Phase 1 included three developers. Phase 2 included 11 primary care physicians, 10 allied health care professionals, and 11 parents of children with asthma. Phase 2 interviews were based on the 14 domains of the Theoretical Domains Framework (TDF). Transcribed interviews were analyzed using a directed content analysis. Key assumptions by the developers about the intervention, and beliefs by others about the barriers and enablers of the targeted behaviors were identified. Results: Eight TDF domains mapped onto the assumptions of the pathway as described by the intervention developers. Interviews with health care professionals and parents identified nine TDF domains that influenced the targeted behaviors: knowledge, skills, beliefs about capabilities, social/professional role and identity, beliefs about consequences, environmental context and resources, behavioral regulation, social influences, and emotions. Conclusions: Barriers and enablers perceived by health care professionals and parents that influenced asthma management will inform the optimization of the PCAPP prior to its evaluation.     

Innovations in access to care: a patient-centered approach

To receive health care, patients with nonemergent problems must gain access to a complex, interdependent ambulatory care system currently structured around the conventional office appointment model. The system does not effectively accommodate diverse patient needs and preferences, contributing to both overuse and underuse of health care resources. A patient-centered access model would help patients secure appropriate and preferred medical assistance when and where it is needed. Characteristics of patient-centered access include availability, appropriateness, preference, and timeliness. One or more of these characteristics often is missing in patients' health care experiences. The goal of this paper is to present patient-centered access as an integrated concept and philosophy to provide context for evaluating specific access initiatives. On the basis of an assessment of existing literature, 3 organizing principles of patient-centered access are proposed and discussed: work at the high end of expertise; align care with need and preference; and serve when service is needed. Patient-centered access warrants serious consideration, given the stakes involved for patients, providers, and payers. Few concepts support all 6 of the Institute of Medicine's aims for the 21st century: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equitability. Patient-centered access is such a concept.     

HIV voluntary counselling and testing in community health services

HIV voluntary counseling and testing (VCT) has been given low priority as a possible strategy for combating HIV in developing countries. This is because of the high demands on logistics and skills that the intervention entails. It is the view that individuals have low motivation to know their test results and modify behavior, and the nonexistence of medical care that could make a difference. Although studies on the benefits and efficiency of VCT have shown that the intervention is effective in promoting behavioral change and is cost-effective as well, there is still a need to make VCT accessible to those who desperately need it and to expand and render it more acceptable, innocuous, and less expensive. To this effect, access should first be provided in existing community health services. In addition, other standards of quality necessary for the implementation of VCT services include building up of capacity and infrastructure, respect of confidentiality, counseling of couples when needed and feasible, availability of psychosocial support beyond the post-test period, and avoidance of coercion and social stigma and their consequences.     

The cost-effectiveness of expanded HIV counselling and testing in primary care settings: a first look

OBJECTIVE: To estimate the cost-effectiveness of approaches to expanded HIV counselling and testing. DESIGN: A cost-effectiveness analysis. SETTING: Primary care practices in the USA. PARTICIPANTS: New patient visits. INTERVENTIONS: Two approaches were examined: (i) requesting all patients to complete an HIV-risk screening instrument, with counselling as well as testing offered only to patients disclosing risk factors ('risk histories' option); and (ii) routine offering of voluntary testing to all patients, with consent obtained but no pre-test counselling ('routine testing'). MAIN OUTCOME MEASURES: The primary outcome was the cost per infection identified. We also examined: (i) the costs and numbers of infections averted if individuals change their risk behaviours; and (ii) the additional years of life and quality-adjusted life years (QALY) gained as a result of earlier HIV testing and treatment for infected individuals. RESULTS: Routine testing is the most cost-effective approach to identifying infected individuals at an incremental cost of US$4200 per infection identified. Although using risk histories is more costly and less effective than routine testing, it becomes similarly cost-effective using plausible ranges for sensitivity analyses. If at least 10% of HIV-positive individuals change their behavior, both routine testing and using risk histories would save money. If testing identifies infected individuals one year earlier than they otherwise would have been diagnosed, routine testing would cost US$22000 per QALY gained. CONCLUSION: Routine testing is the most cost-effective approach to identifying new HIV infections. However, using risk histories may be similarly cost-effective under various assumptions. Both routine testing and using risk histories are more cost-effective than current practices.     

Ancillary services and retention of youth in HIV care

The purpose of this prospective study was to test the relationship between receipt of ancillary services (case management, advocacy, counseling) over six months and retention of youth in HIV care in the subsequent six months. Medical records of 75 youth (ages 16-25) enrolled in a comprehensive HIV care program at a university-affiliated medical center in Detroit, Michigan were reviewed for receipt of services in a 12-month period. The youth program offered medical and ancillary services in a one-stop-shopping model. The expectation for medical care for youth was at least quarterly medical appointments. A three-point scale was constructed with a score of '0' indicating no gaps (at least one medical care appointment every three months in a six-month period), a score of '1' indicating one gap (no appointment in one of the two quarters) and a score of '2' indicating two gaps (no appointments in six months). Increased receipt of ancillary services in the first six months predicted lower gap scores in the second six months, even controlling for gap scores in the first six months. Counseling appointments were the strongest predictor. Preliminary results suggest the continued need for resources allocated to ancillary services to support retention in care.