Background Patients’ life contexts are increasingly recognized as important, as evidenced by growing attention to the Social Determinants of Health (SDoH). This attention may be particularly valuable for patients with complex needs, like those with HIV, who are more likely to experience age-related comorbidities, mental health or substance use issues. Understanding patient perceptions of their life context can advance SDoH approaches. Objectives We sought to understand how aging patients with HIV think about their life context and explored if and how their reported context was documented in their electronic medical records (EMRs). Design We combined life story interviews and EMR data to understand the health-related daily life experiences of patients with HIV. Patients over 50 were recruited from two US Department of Veterans Affairs HIV clinics. Narrative analysis was used to organize data by life events and health-related metrics. Key results EMRs of 15 participants documented an average of 19 diagnoses and 10 medications but generally failed to include social contexts salient to patients. In interviews, HIV was discussed primarily in response to direct interviewer questions. Instead, participants raised past trauma, current social engagement, and concern about future health with varying salience. This led us to organize the narratives temporally according to past-, present-, or future-orientation. “Past-focused” narratives dwelled on unresolved experiences with social institutions like the school system, military or marriage. “Present-focused” narratives emphasized daily life challenges, like social isolation. “Future-focused” narratives were dominated by concerns that aging would limit activities. Conclusions A temporally informed understanding of patients’ life circumstances that are the foundation of their individualized SDoH could better focus care plans by addressing contextual concerns salient to patients. Trust-building may be a critical first step in caring for past-focused patients. Present-focused patients may benefit from support groups. Future-focused patients may desire discussing long term care options.
Abstract Background: Rising rates of substance use, particularly the use of synthetic opioids, have led to increases in fatal overdoses and injection-associated infections. Harm reduction, including infection prevention via provision of educational interventions and sterile syringes and other supplies, is an approach to minimize risk of severe outcomes. Although harm reduction services (HRS) are highly evidence-based, implementation in most healthcare settings has been limited. The aim of this study was to identify facilitators and barriers to the implementation of HRS to inform strategies for increasing access and facilitating the adoption of a comprehensive bundle of harm reduction resources within the VHA. Methods: Qualitative interviews were conducted using a semi-structured interview guide. Interviews explored how harm reduction is currently understood and implemented by VHA providers and elicited input on perceived facilitators and barriers to implementation. Data were analyzed using a directed content analysis. After barriers and facilitators were identified, they were mapped to relevant implementation strategies using the Consolidated Framework for Implementation Research - Expert Recommendations for Implementing Change (CFIR – ERIC) tool. Results: 15 interviews with VHA providers (physicians, social workers, pharmacists, and directors of addiction and mental health services) were conducted across 5 sites. Multiple barriers and few facilitators to the provision of HRS were identified. Existing HRS were thought to be fragmented and dependent on the knowledge, time, and comfort level of individual providers. Participants also highlighted stigma around substance use, limited support, and burdensome regulatory requirements. Existing infrastructure, social programming, and local champions were highlighted as facilitators. Given these factors, implementation strategies that may be bundled to promote adoption of HRS include engagement of champions, communications and educational strategies, existing policies, and creation of dashboards, tracking, and feedback systems. Conclusions: HRS are effective and evidence-based, yet their adoption into traditional healthcare settings has been limited. Mapping of barriers to evidence-based implementation strategies may help improve integration of HRS into VHA healthcare, however, challenges addressing stigma remain a substantial barrier. More research is needed to identify implementation strategies that are most effective for addressing barriers imposed by stigma.
Women of color (WOC) account for 83% of new HIV infections among women in the United States. While pre-exposure prophylaxis (PrEP) is a safe, effective HIV prevention method for women, WOC are less likely to be prescribed PrEP than other populations. Guided by an implementation science research framework, we investigated the implementation of a PrEP initiative for WOC in a US city with high HIV incidence. Across three clinical sites, only three WOC were prescribed PrEP after one year. Analysis of qualitative interviews with clinic staff and providers identified time constraints, reluctance to prescribe PrEP, and discomfort with counseling as implementation barriers. Implementation facilitators included staff and leadership support for PrEP, alignment of PrEP services with organizational missions, and having a centralized PrEP Coordinator. By addressing these identified implementation barriers and facilitators, clinic staff and providers can ensure that WOC are provided with the full range of HIV prevention options.
Keeping a contamination free environment in the laboratory has commonly been achieved by one of two ways: a flame or a biosafety cabinet (BSC). However, it has been frequently observed that these two practices have been combined, where a heat source has been used within the BSC. As flames require flammable gasses and cause hot air to rise, it was hypothesized that these could lead to a loss of BSC containment, as BSCs rely on unidirectional downflow air.The objective of this study was to determine whether BSCs can maintain containment when a heat source is operated within the work area.Several heat sources (Bunsen burner, High Heat Bunsen Burner, Spirit Lamp and Bacti-cinerator) were placed within two sizes of BSCs (4-foot and 6-foot), and smoke was used to visualize airflow disturbances, air cleanliness was measured by particle counting , and aerosol microbiological testing was conducted to ascertain containment. The risk of introducing a flammable gas into a BSC was also calculated.Large flamed Bunsen burners were found to have the most detrimental effects on the ability of the BSC to maintain containment, especially in the center of the work area, while the smaller heat sources were more variable. Containment was completely lost in the 4-foot BSC, whereas the 6-foot BSC was capable of maintaining containment in only a few conditions. The BSC was also calculated to be able to maintain the required volume of flammable gas needed to operate the burners, not taking into consideration unintended leaks.Overall, it was determined that BSCs cannot operate safely and reliably while housing a heat source, as it could cause unexpected contamination of the work or the worker, or BSC ignition or explosion.
Explore the perceived benefits of a Veterans Health Administration (VHA) geriatric specialty telemedicine service (GRECC Connect) among rural, older patients and caregivers to contribute to an assessment of its quality and value.In Spring 2021, we interviewed a geographically diverse sample of rural, older patients and their caregivers who participated in GRECC Connect telemedicine visits.A cross-sectional qualitative study focused on patient and caregiver experiences with telemedicine, including perceived benefits and challenges.We conducted 30 semi-structured qualitative interviews with rural, older (≥65) patients enrolled in the VHA and their caregivers via videoconference or phone. Interviews were recorded, transcribed, and analyzed using a rapid qualitative analysis approach.Participants described geriatric specialty telemedicine visits focused on cognitive assessments, tailored physical therapy, medication management, education on disease progression, support for managing multiple comorbidities, and suggestions to improve physical functioning. Participants reported that, in addition to prescribing medications and ordering tests, clinicians expedited referrals, coordinated care, and listened to and validated both patient and caregiver concerns. Perceived benefits included improved patient health; increased patient and caregiver understanding and confidence around symptom management; and greater feelings of empowerment, hopefulness, and support. Challenges included difficulty accessing some recommended programs and services, uncertainty related to instructions or follow-up, and not receiving as much information or treatment as desired. The content of visits was well aligned with the domains of the Age-Friendly Health Systems and Geriatric 5Ms frameworks (Medication, Mentation, Mobility, what Matters most, and Multi-complexity).Alignment of patient and caregiver experiences with widely-used models of comprehensive geriatric care indicates that high-quality geriatric care can be provided through virtual modalities. Additional work is needed to develop strategies to address challenges and optimize and expand access to geriatric specialty telemedicine.
Lung cancer screening (LCS) can reduce lung cancer mortality with close follow-up and adherence to management recommendations. Little is known about factors associated with adherence to LCS in real-world practice, with data limited to case series from selected LCS programs.
Objective
To analyze adherence to follow-up based on standardized follow-up recommendations in a national cohort and to identify factors associated with delayed or absent follow-up.
Design, Setting, and Participants
This retrospective cohort study was conducted in Veterans Health Administration (VHA) facilities across the US. Veterans were screened for lung cancer between 2015 to 2019 with sufficient follow-up time to receive recommended evaluation. Patient- and facility-level logistic regression analyses were performed. Data were analyzed from November 26, 2019, to December 16, 2020.
Main Outcomes and Measures
Receipt of the recommended next step after initial LCS according to Lung CT Screening Reporting & Data System (Lung-RADS) category, as captured in VHA or Medicare claims.
Results
Of 28 294 veterans (26 835 [94.8%] men; 21 969 individuals [77.6%] were White; mean [SD] age, 65.2 [5.5] years) who had an initial LCS examination, 17 863 veterans (63.1%) underwent recommended follow-up within the expected timeframe, whereas 3696 veterans (13.1%) underwent late evaluation, and 4439 veterans (15.7%) had no apparent evaluation. Facility-level differences were associated with 9.2% of the observed variation in rates of late or absent evaluation. In multivariable-adjusted models, Black veterans (odds ratio [OR], 1.19 [95% CI, 1.10-1.29]), veterans with posttraumatic stress disorder (OR, 1.13 [95% CI, 1.03-1.23]), veterans with substance use disorders (OR, 1.11 [95% CI, 1.01-1.22]), veterans with lower income (OR, 0.88 [95% CI, 0.79-0.98]), and those living at a greater distance from a VHA facility (OR, 1.06 [95% CI, 1.02-1.10]) were more likely to experience delayed or no follow-up; veterans with higher risk findings (Lung-RADS category 4 vs Lung-RADS category 1: OR, 0.35 [95% CI, 0.28-0.43]) and those screened in high LCS volume facilities (OR, 0.38 [95% CI, 0.21-0.67]) or academic facilities (OR, 0.86 [95% CI, 0.80-0.92]) were less likely to experience delayed or no follow-up. In sensitivity analyses, varying how stringently adherence was defined, expected evaluation ranged from 14 486 veterans (49.7%) under stringent definitions to 20 578 veterans (78.8%) under liberal definitions.
Conclusions and Relevance
In this cohort study that captured follow-up care from the integrated VHA health care system and Medicare, less than two-thirds of patients received timely recommended follow-up after initial LCS, with higher risk of delayed or absent follow-up among marginalized populations, such as Black individuals, individuals with mental health disorders, and individuals with low income, that have long experienced disparities in lung cancer outcomes. Future work should focus on identifying facilities that promote high adherence and disseminating successful strategies to promote equity in LCS among marginalized populations.
