Burden of Medically Attended Diarrhea and Outpatient Clostridioides difficile Infection Among Persons in 2 Large Integrated Healthcare Settings, 2016-2021

Background

Identification of Clostridioides difficile infection (CDI) in the community setting is increasing. We describe testing for CDI among patients with medically attended diarrhea (MAD) in the outpatient setting, and the incidence of outpatient CDI.

Methods

This was a retrospective cohort study among members ≥18 years of age from Kaiser Permanente Southern California and Kaiser Permanente Northwest from 1 January 2016 through 31 December 2021. MAD was identified by outpatient diarrheal International Classification of Diseases, Tenth Revision diagnosis codes, and CDI through positive laboratory results. Outpatient CDI was defined by no hospitalization ≤7 days after specimen collection. Incidence rates (IRs) of outpatient CDI were stratified by select demographic and clinical variables. Outpatient CDI burden 12 months following index date was measured by CDI-associated healthcare visits, and CDI testing and treatment.

Results

We identified 777 533 MAD episodes; 12.1% (93 964/777 533) were tested for CDI. Of those tested, 10.8% (10 110/93 964) were positive. Outpatient CDI IR was 51.0 (95% confidence interval [CI], 49.8-52.2) per 100 000 person-years, decreasing from 58.2 (95% CI, 55.7-60.7) in 2016 to 45.7 (95% CI, 43.7-47.8) in 2021. Approximately 44% (n = 4200) received an antibiotic 30 days prior to index date and 84.1% (n = 8006) CDIs were "community-associated" (no hospitalizations 12 weeks prior to index date). Of outpatient CDIs, 6.7% (n = 526) had a CDI-associated hospitalization ≤12 months.

Conclusions

There was a high incidence of outpatient CDI despite infrequent CDI testing among patients with MAD. The majority of those with outpatient CDI had no recent antibiotic use and no recent hospitalization. Further studies are needed to understand the source and management of medically attended outpatient CDI.

Discrimination and adherence in a cross-sectional study of Latino sexual minority men with HIV: Coping with discrimination as a mediator and coping self-efficacy as a moderator

Discrimination is associated with antiretroviral therapy non-adherence and reduced well-being among people with HIV. We examined the potential for coping to mediate the associations between intersectional discrimination and non-adherence and coping self-efficacy (confidence in one's ability to cope with discrimination) as a moderator that may buffer the negative effects of discrimination on non-adherence in a cross-sectional convenience sample of 82 Latino sexual minority men with HIV. In bivariate linear regressions, discrimination targeting Latino ethnic origin, undocumented residency status, and sexual orientation were each significantly associated with lower self-reported antiretroviral therapy non-adherence (percentage of prescribed doses taken in the last month) and greater use of disengagement coping (denial, substance use, venting, self-blame, behavioral disengagement). Associations between discrimination targeting Latino ethnicity and non-adherence, and discrimination targeting undocumented residency status and non-adherence, were each mediated by disengagement coping responses. Moderation analyses highlighted significant discrimination by coping self-efficacy interaction effects-both coping self-efficacy for problem solving and stopping unpleasant emotions/thoughts each moderated the associations between Latino discrimination and adherence, between undocumented residency status discrimination and adherence, and between HIV discrimination and adherence. Coping self-efficacy for getting social support moderated the association between undocumented residency status discrimination and adherence. Further, the interaction coefficients across models indicated that the negative effects of discrimination on adherence were attenuated at higher levels of coping self-efficacy. Findings highlight the need for structural interventions that reduce-and ultimately eliminate-discrimination, and interventions that address the harmful effects of discrimination and adherence improvement interventions to enhance coping skills among people faced with intersectional discrimination.

Chronic and Sustained High-Dose Opioid Use in an Integrated Health System

INTRODUCTION

The Centers for Disease Control and Prevention Guideline for Prescribing Opioids for Chronic Pain released in 2016 had led to decreases in opioid prescribing. This study sought to examine chronic and sustained high-dose prescription opioid use in an integrated health system.

METHODS

A serial cross-sectional study was conducted in 2021 to estimate the annual age-adjusted prevalence and incidence of chronic and high-dose opioid use among demographically diverse noncancer adults in an integrated health system in Southern California during 2013-2020. Interrupted time-series analysis with segmented regression was conducted to estimate changes in the trends in annual rates before (2013-2015) and after (2017-2020) the 2016 guideline, treating 2016 as a wash-out period.

RESULTS

Prevalence and incidence of chronic use and sustained high-dose use had started to decrease after a health system intervention program before the 2016 Centers for Disease Control and Prevention guideline release and continued to decline after the guideline. Among those with sustained high-dose use, there was a substantial decrease in persons with an average daily dosage ≥90 morphine milligram equivalent and concurrent benzodiazepine use. An accelerated decrease in prevalent chronic use after the guideline was observed (slope change: -11.1 [95% CI= -20.3, -1.9] users/10,000 person-years, p=0.03). The incidence of chronic use and sustained high-dose use continued to decrease after the guideline release but at a slower pace.

CONCLUSIONS

Implementing evidence-based prescribing guidelines was associated with a decrease in chronic and sustained high-dose prescription opioid use.

US public charge policy and Latinx immigrants' thoughts about health and healthcare utilization

OBJECTIVES

We examined Latinx immigrants' perceptions of US policy related to restrictions on immigrants' use of public resources and their thoughts about the influence of these on immigrants' healthcare utilization.

DESIGN

A series of 16 focus group discussions with Latinx immigrant men and women (documented and undocumented) (N = 130) were conducted between May and July 2017 across four US cities.

RESULTS

Four central themes emerged: participants attributed the limited resources available for affordable healthcare for many uninsured US immigrants (both documented and undocumented) to the US government's view of immigrants as burdens on public resources and its subsequent unwillingness to dedicate funds for their care; participants expressed concerns, some unfounded, about negative immigration ramifications arising from diagnosis with health conditions perceived to be serious and/or expensive to treat; participants noted that some immigrants avoided using health programs and services to which they were entitled because of immigration concerns; finally, participants described how access to information on immigration laws and healthcare resources, and conversely, misinformation about these, influenced healthcare utilization.

CONCLUSIONS

Participants were acutely aware of the image of immigrants as public charges or potential burdens on government resources that underlies US immigration policy. In some cases, participants came to inaccurate and potentially harmful conclusions about the substance of laws and regulations based on their beliefs about the government's rejection of immigrants who may burden public resources. This underscores the importance of ensuring that immigrants have access to information on immigration-related laws and regulations and on healthcare resources available to them. Participants noted that access to information also fostered resilience to widespread misinformation. Importantly, however, participants' beliefs had some basis in US immigration policy discourse. Law and policy makers should reconsider legislation and political commentary that frame self-reliance, the guiding principle of US immigration policy, in terms of immigrants' use of publicly funded healthcare resources.

Pilot Randomized Controlled Trial of an Intervention to Improve Coping with Intersectional Stigma and Medication Adherence Among HIV-Positive Latinx Sexual Minority Men

We developed and pilot-tested an eight-session community-based cognitive behavior therapy group intervention to improve coping with intersectional stigma, address medical mistrust, and improve antiretroviral treatment adherence. Seventy-six HIV-positive Latinx sexual minority men (SMM; 38 intervention, 38 wait-list control) completed surveys at baseline, and 4- and 7-months post-baseline. Adherence was electronically monitored. Intention-to-treat, repeated-measures regressions showed improved adherence in the intervention vs. control group from baseline to follow-up [electronically monitored: b (95% CI) 9.24 (- 0.55, 19.03), p = 0.06; self-reported: b (95% CI) 4.50 (0.70, 8.30), p = .02]. Intervention participants showed marginally decreased negative religious coping beliefs in response to stigma [b (95% CI) = - 0.18 (- 0.37, 0.01), p = .06], and significantly lower medical mistrust [b (95% CI) = - 0.47 (- 0.84, - 0.09), p = .02]. Our intervention holds promise for improving HIV outcomes by empowering Latinx SMM to leverage innate resilience resources when faced with stigma.ClinicalTrials.gov ID (TRN): NCT03432819, 01/31/2018.

The acceptability and feasibility of a pilot study examining the impact of a mobile technology-based intervention informed by behavioral economics to improve HIV knowledge and testing frequency among Latinx sexual minority men and transgender women

Background

We developed a novel intervention that uses behavioral economics incentives and mobile-health text messages to increase HIV knowledge and testing frequency among Latinx sexual minority men and Latinx transgender women. Here we provide a theoretically-grounded assessment regarding the intervention’s acceptability and feasibility.

Methods

We conducted 30-min exit interviews with a stratified sample of participants (n = 26 Latinx sexual minority men, 15 Latinx transgender women), supplemented with insights from study staff (n = 6). All interviews were recorded, transcribed, and translated for a content analysis using Dedoose. Cohen’s Kappa was 89.4% across coded excerpts. We evaluated acceptability based on how participants cognitively and emotionally reacted to the intervention and whether they considered it to be appropriate. We measured feasibility based on resource, scientific and process assessments (e.g., functionality of text messaging service, feedback on study recruitment procedures and surveys).

Results

Regarding acceptability, most participants clearly understood the intervention as a program to receive information about HIV prevention methods through text messages. Participants who did not complete the intervention shared they did not fully understand what it entailed at their initial enrollment, and thought it was a one-time engagement and not an ongoing program. Though some participants with a higher level of education felt the information was simplistic, most appreciated moving beyond a narrow focus on HIV to include general information on sexually transmitted infections; drug use and impaired sexual decision-making; and differential risks associated with sexual positions and practices. Latinx transgender women in particular appreciated receiving information about Pre-Exposure Prophylaxis. While participants didn’t fully understand the exact chances of winning a prize in the quiz component, most enjoyed the quizzes and chance of winning a prize. Participants appreciated that the intervention required a minimal time investment. Participants shared that the intervention was generally culturally appropriate. Regarding feasibility, most participants reported the text message platform worked well though inactive participants consistently said technical difficulties led to their disengagement. Staff shared that clients had varying reactions to being approached while being tested for HIV, with some unwilling to enroll and others being very open and curious about the program. Both staff and participants relayed concerns regarding the length of the recruitment process and study surveys.

Conclusions

Our theoretically-grounded assessment shows the intervention is both acceptable and feasible.

Trial registration

The trial was registered on May 5, 2017 with the ClinicalTrials.gov registry [NCT03144336].

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10335-5.

Rapid mixed-methods assessment of COVID-19 impact on Latinx sexual minority men and Latinx transgender women

We conducted a rapid, mixed-methods assessment to understand how COVID-19 affected Latinx sexual minority men (LSMM) and transgender women (LTGW). Using a computer-assisted telephone interviewing software, one interviewer called 52 participants (randomly sampled from a larger HIV prevention pilot study aiming to increase HIV knowledge and testing frequency; n = 36 LSMM and n = 16 LTGW) between 04/27/20-05/18/20. We quantified core domains using the Epidemic-Pandemic Impacts Inventory scale and provided important context through open-ended qualitative questions assessing: 1) COVID-19 infection history and experiences with quarantine; 2) Health and healthcare access; 3) Employment and economic impact of COVID-19. Participants reported increases in physical conflict or verbal arguments with a partner (13.5%) or other adult(s) (19.2%) due to stressors associated with the safer-at-home order. Participants also reported increased alcohol consumption (23.1%), problems with sleep (67.3%) and mental health (78.4%). Further, disruptions in access to Pre-Exposure Prophylaxis or PrEP-a daily pill to prevent HIV-occurred (33.3% of 18 participants who reported being on PrEP). Many said they received less medical attention than usual (34.6%), and LTGW reported delays in critical gender-affirming hormones/procedures. Half of the participants lost their jobs (50.0%); many undocumented participants relayed additional financial concerns because they did not qualify for financial assistance. Though no COVID-19 infections were noted, COVID-19 dramatically impacted other aspects of health and overall wellbeing of LSMM and LTGW. Public health responses should address the stressors faced by LSMM and LTGW during the COVID-19 pandemic and the impact on wellbeing.

Strategies for Improving Mobile Technology-Based HIV Prevention Interventions With Latino Men Who Have Sex With Men and Latina Transgender Women

Mobile technology-based interventions show promise for conveying HIV prevention information to Latino men who have sex with men (LMSM) and Latina transgender women (LTGW); however, implementing such interventions can pose serious challenges. To understand how to adapt existing interventions for these populations, we conducted nine focus groups (N = 91 participants, 52 LMSM, 39 LTGW) in Los Angeles, California. We used a rapid assessment process to create narrative reports that we examined using thematic analysis to explore differences across sites and between LMSM and LTGW. Lessons learned: requiring smartphone use could diminish participation of poor participants; sending personalized messages on the same days and times can help participants anticipate receiving study information; working with community partners is essential for building trust; recognizing different language literacies and diverse countries of origin can improve the cultural competency of intervention materials. Addressing these challenges may enhance efforts to address the HIV prevention needs of these communities.

Using Behavioral Economics to Promote HIV Prevention for Key Populations

In this short communication, we discuss some key behavioral economic (BE) biases that likely minimize HIV prevention efforts, explore why certain key populations such as men who have sex with men or transgender women-may be more likely to succumb to these biases, and suggest how incentives informed by BE can support these populations in their effort to remain HIV-negative. Based on our formative work in an ongoing study, we discuss two important insights regarding the use of incentives to inform future HIV prevention efforts. First, participants often expressed more excitement for prizes that were viewed as fun (e.g., movie gift cards) or luxurious (e.g., cosmetics gift cards) rather than necessities (e.g., grocery store gift cards) of the same financial value and suggests that including an element of fun can be a powerful tool for incentivizing safe HIV-related behavior. Second, participants preferred not to be "paid" to display health behaviors, indicating the way incentives are given out (and perceived) is central to their success. Going forward, a BE perspective can help improve the impact of incentives - and increase their cost-effectiveness by carefully adapting them to the preferences of their recipients.

Behavioral economics-based incentives supported by mobile technology on HIV knowledge and testing frequency among Latino/a men who have sex with men and transgender women: Protocol for a randomized pilot study to test intervention feasibility and acceptability

Background

Mobile Technology and Incentives (MOTIVES) is a randomized pilot study of a mobile technology-based and behavioral economics-supported HIV prevention intervention. Behavioral economics (BE) uses financial incentives in a way that departs from the traditional focus on large monetary payments. Instead, BE suggests that relatively small “nudges” can effectively initiate and sustain behavior change. This pilot study examines the feasibility and acceptability of an HIV prevention intervention that uses text messages in combination with BE incentives to improve retention of HIV prevention information and increase frequency of HIV testing among Latino/a men who have sex with men (MSM) and transgender women (TGW). The pilot will also estimate mission-critical design parameters with point and confidence interval estimates of the intervention to inform a future, fully powered effectiveness study.

Methods

The project will be conducted in collaboration with Bienestar Human Services, Inc. (Bienestar), a non-profit community-based service organization. The intervention is being tested in a small, randomized controlled trial to pilot the intervention’s feasibility and acceptability among 200 Latino/a MSM and TGW from Bienestar’s HIV testing sites. Information on feasibility will include recruitment, refusal, and retention rates as well as message sending success rates; acceptability will include perceived appropriateness based on responses to the intervention. Participants will be randomized into either the “information only” control group (e.g. receiving text messages with HIV prevention information) or the “information plus” intervention group (e.g. additionally receiving quiz questions that provide the possibility of winning prizes). Participants will be followed for 12 months from enrollment. In addition to using data abstracted from Bienestar’s routine data collection mechanisms, we will also collect survey data (blinded outcome assessment) from participants at 0, 6, and 12 months to provide an initial assessment of whether incentives affect their level of HIV knowledge and testing frequency.

Discussion

If shown to be acceptable, feasible, and resource-efficient, MOTIVES will provide an innovative way to communicate the latest HIV prevention information and support trimestral HIV screening among Latino/a MSM and TGW.

Trial registration

ClinicalTrials.gov, NCT03144336. Registered on 5 May 2017.