Decisions by Default: Incomplete and Contradictory MOLST in Emergency Care

Objectives

What patients intend when they make health care choices and whether they understand the meaning of orders for life-sustaining treatment forms is not well understood. The purpose of this study was to analyze the directives from a sample of emergency department (ED) patients' MOLST forms.

Examining Early Childhood Health Outcomes of Children Born Late Preterm in Urban Manitoba

Objective The late preterm population [34–36 weeks gestational age (GA)] is known to incur increased morbidity in the infancy stage compared to the population born at term (39–41 weeks GA). This study aimed to examine the health of these children during their early childhood years, with specific attention to the role of socioeconomic status. Methods A retrospective cohort study was conducted using data from the Manitoba Centre for Health Policy, including all live-born children born at 34–36 and 39–41 weeks GA in urban Manitoba between 2000 and 2005 (n?=?28,100). Multivariable logistic regression was used to examine the association of GA with early childhood morbidity after controlling for maternal, child and family level variables. Results The late preterm population was found to have significantly greater adjusted odds of lower respiratory tract infections in the preschool years (aOR?=?1.59 [1.24, 2.04]) and asthma at school age (aOR?=?1.33 [1.18, 1.47]) compared to the population born at term. The groups also differed in health care utilization at ages 4 (aOR?=?1.19 [1.06,1.34]) and 7 years (aOR?=?1.24 [1.09, 1.42]). Additional variables associated with poor outcomes suggest that social deprivation and GA simultaneously have a negative impact on early childhood development. Conclusions for Practice Adjustment for predictors of poor early childhood development, including socioeconomic status, were found to attenuate but not eliminate health differences between children born late preterm and children born at term. Poorer health outcomes that extend into childhood have implications for practice at the population level and suggest a need for further follow-up post discharge.     

Incremental cost and cost-effectiveness of low-dose,high-frequency training in basic emergency obstetric and newborn care as compared to status quo: part of a cluster-randomized training intervention evaluation in Ghana

Background

Low-dose, high-frequency (LDHF) training is a new approach best practices to improve clinical knowledge, build and retain competency, and transfer skills into practice after training. LDHF training in Ghana is an opportunity to build health workforce capacity in critical areas of maternal and newborn health and translate improved capacity into better health outcomes.

Methods

This study examined the costs of an LDHF training approach for basic emergency obstetric and newborn care and calculates the incremental cost-effectiveness of the LDHF training program for health outcomes of newborn survival, compared to the status quo alternative of no training. The costs of LDHF were compared to costs of traditional workshop-based training per provider trained. Retrospective program cost analysis with activity-based costing was used to measure all resources of the LDHF training program over a 3-year analytic time horizon. Economic costs were estimated from financial records, informant interviews, and regional market prices. Health effects from the program’s impact evaluation were used to model lives saved and disability-adjusted life years (DALYs) averted. Uncertainty analysis included one-way and probabilistic sensitivity analysis to explore incremental cost-effectiveness results when fluctuating key parameters.

Results

For the 40 health facilities included in the evaluation, the total LDHF training cost was $823,134. During the follow-up period after the first LDHF training—1 year at each participating facility—approximately 544 lives were saved. With deterministic calculation, these findings translate to $1497.77 per life saved or $53.07 per DALY averted. Probabilistic sensitivity analysis, with mean incremental cost-effectiveness ratio of $54.79 per DALY averted ($24.42–$107.01), suggests the LDHF training program as compared to no training has 100% probability of being cost-effective above a willingness to pay threshold of $1480, Ghana’s gross national income per capita in 2015.

Conclusion

This study provides insight into the investment of LDHF training and value for money of this approach to training in-service providers on basic emergency obstetric and newborn care. The LDHF training approach should be considered for expansion in Ghana and integrated into existing in-service training programs and health system organizational structures for lower cost and more efficiency at scale.

     

Comparative Effectiveness of a Faith-Based HIV Intervention for African American Women: Importance of Enhancing Religious Social Capital

Objectives. We assessed the effectiveness of P4 for Women, a faith-based HIV intervention.Methods. We used a 2-arm comparative effectiveness trial involving 134 African American women aged 18 to 34 years to compare the effectiveness of the Centers for Disease Control and Prevention–defined evidence-based Sisters Informing Sisters about Topics on AIDS (SISTA) HIV intervention with P4 for Women, an adapted faith-based version of SISTA. Participants were recruited from a large black church in Atlanta, Georgia, and completed assessments at baseline and follow-up.Results. Both SISTA and P4 for Women had statistically significant effects on this study’s primary outcome—consistent condom use in the past 90 days—as well as other sexual behaviors. However, P4 for Women also had statistically significant effects on the number of weeks women were abstinent, on all psychosocial mediators, and most noteworthy, on all measures of religious social capital. Results were achieved by enhancing structural social capital through ministry participation, religious values and norms, linking trust and by reducing negative religious coping. High intervention attendance may indicate the feasibility of conducting faith-based HIV prevention research for African American women.Conclusions. P4 for Women enhanced abstinence and safer sex practices as well as religious social capital, and was more acceptable than SISTA. Such efforts may assist faith leaders in responding to the HIV epidemic in African American women.One little-understood social determinant of health is religion.1 Although 56% of all Americans consider religion very important in their lives, this percentage approaches 80% among African Americans.2 Of all major racial and ethnic groups in the United States, African Americans are most likely to report a formal religious affiliation. Nearly 60% of Black adults are affiliated with historically Black Protestant churches. African Americans in the South are more likely than African Americans from other regions of the United States to belong to historically Black churches. The Black church is often among the most visible, respected and credible agencies in the African American community3,4 and is acknowledged as a critical partner in improving ethical engagement of African Americans in health research.Research has demonstrated that religious participation reduces mortality risks5–14 and improves health status6,7 and quality of life for African Americans.6,7,15–17 As early as the 1920s, Black churches were involved in outreach programs to address the health needs of community members through the provision of free clinics.18 Today, churches remain increasingly popular settings in which to conduct health research among African Americans. Scarce resources as well as conflicts between the historically Black church’s role of worship and its role in providing HIV-related services initially hindered efforts to address HIV.19 However, recently, faith-based HIV prevention research emphasizing abstinence among adolescents has emerged.20African American women are disproportionately affected by HIV.21 Because African American women constitute more than 60% of the congregation in historically Black churches,2 serve in key positions in sustaining the churches’ social programs (ministries), and tend to seek solace from faith-based institutions, a closer examination of the church’s role in HIV prevention efforts with this population should be explored. The current effectiveness study hypothesized that P4 for Women would be more appropriate in faith-based settings compared with the widely disseminated, Centers for Disease Control and Prevention (CDC)-defined, evidence-based HIV intervention for African American women called Sisters Informing Sisters about Topics on AIDS (SISTA),22 which is often delivered in public health venues. P4 for Women was created as a faith-based adaptation of SISTA23,24 delivered at a historically Black church in the Atlanta, Georgia, metropolitan area.     

Mobile Phone–based Syndromic Surveillance System,Papua New Guinea

The health care system in Papua New Guinea is fragile, and surveillance systems infrequently meet international standards. To strengthen outbreak identification, health authorities piloted a mobile phone–based syndromic surveillance system and used established frameworks to evaluate whether the system was meeting objectives. Stakeholder experience was investigated by using standardized questionnaires and focus groups. Nine sites reported data that included 7 outbreaks and 92 cases of acute watery diarrhea. The new system was more timely (2.4 vs. 84 days), complete (70% vs. 40%), and sensitive (95% vs. 26%) than existing systems. The system was simple, stable, useful, and acceptable; however, feedback and subnational involvement were weak. A simple syndromic surveillance system implemented in a fragile state enabled more timely, complete, and sensitive data reporting for disease risk assessment. Feedback and provincial involvement require improvement. Use of mobile phone technology might improve the timeliness and efficiency of public health surveillance.     

The Role of Family History of Cancer on Cervical Cancer Screening Behavior in a Population-based Survey of Women in the Southeastern United States

BackgroundOur objective was to determine the association of self-reported family history of cancer (FHC) on cervical cancer screening to inform a potential link with cancer preventive behaviors in a region with persistent cancer disparities.MethodsSelf-reported FHC, Pap test behavior, and access to care were measured in a statewide population-based survey of human papillomavirus and cervical cancer (n = 918). Random-digit dial, computer-assisted telephone interviews were used to contact eligible respondents (adult [ages 18–70] women in South Carolina with landline telephones]. Logistic regression models were estimated using STATA 12.FindingsAlthough FHC+ was not predictive (odds ratio [OR], 1.17; 95% confidence interval [CI], 0.55–2.51), private health insurance (OR, 2.35; 95% confidence interval [CI], 1.15–4.81) and younger age (18–30 years: OR, 7.76; 95% CI, 1.91, 3.16) were associated with recent Pap test behavior. FHC and cervical cancer screening associations were not detected in the sample.ConclusionsFindings suggest targeting older women with screening recommendations and providing available screening resources for underserved women.     

Dynamics of functional aging based on latent-class trajectories of activities of daily living

PurposeThis study sought to identify and characterize major patterns of functional aging based on activities of daily living (ADL).MethodsWe followed 754 community-living adults aged 70 years or older monthly for ADLs, instrumental ADLs, hospitalization and restricted activity over 10 years. A generalized growth mixture model was used to identify trajectories of ADL disability across seven 18-month intervals. Cumulative burdens of disability and morbidity from different trajectories were examined using a generalized estimating equation Poisson model.ResultsFive distinct trajectories emerged. The predominant trajectory maintained ADL independence, with membership probability being 61.6%. The remaining trajectories either stayed at low (1 or 2 ADLs, 13.6%) or high (3 or 4 ADLs, 7.0%) levels of disability or declined gradually toward low (11.2%) or high (6.5%) disability. The independent trajectory was associated with the lowest burdens of disability and morbidity and a decreasing time trend of restricted activity, whereas the high disability trajectory demonstrated opposite trends. About 31% of the cohort remained in the same trajectory throughout the follow-up period.ConclusionsThe course of functional aging is heterogeneous and dynamic. Although most older adults maintain functional autonomy, some may experience persistent disability or progress toward severe disability with substantial morbidity.     

Identification and Assessment of Public Health Surveillance Gaps under the IHR (2005)

Objective

To conceive and develop a model to identify gaps in public health surveillance performance and provide a toolset to assess interventions, cost, and return on investment (ROI).

Introduction

Under the revised International Health Regulations (IHR [2005]) one of the eight core capacities is public health surveillance. In May 2012, despite a concerted effort by the global community, the World Health Organization (WHO) reported out that a significant number of member states would not achieve targeted capacity in the IHR (2005) surveillance core capacity.Currently, there is no model to identify and measure these gaps in surveillance performance. Likewise, there is no toolset to assess interventions by cost and estimate the ROI.We developed a new conceptual framework that: (1) described the work practices to achieve effective and efficient public health surveillance; (2) could identify impediments or gaps in performance; and (3) will assist program managers in decision making.

Methods

Published articles and grey-literature reports, manuals and logic model examples were gathered through a literature review of PubMed, Web of Science, Google Scholar, and other databases. Logic models were conceived by categorizing discrete surveillance inputs, activities, outputs, and outcomes. Indicators were selected from authoritative sources or developed and then mapped to the logic model elements. These indicators will be weighted using the principle component analysis (PCA), a method for enhanced precision of statistical analysis. Finally, on the front end of the tool, indicators will graphically measure the surveillance gap expressed through the tool’s architecture and provide information using an integrated cost-impact analysis.

Results

We developed five public health surveillance logic models: for IHR (2005) compliance; event-based; indicator-based; syndromic; and predictive surveillance domains. The IHR (2005) domain focused on national-level functionality, and the others described the complexities of their specific surveillance work practices. Indicators were then mapped and linked to all logic model elements.

Conclusions

This new framework, intended for self-administration at the national and subnational levels, measured public health surveillance gaps in performance and provided cost and ROI information by intervention. The logic model framework and PCA methodology are tools that both describe work processes and define appropriate variables used for evaluation. However, both require real-world data. We recommend pilot testing and validation of this new framework. Once piloted, the framework could be adapted for the other IHR (2005) core capacities.