Racial differences in testing for infectious diseases: An analysis of jail intake data.

HIV and hepatitis C virus (HCV) testing for all people in jail is recommended by the CDC. In the community, there are barriers to HIV and HCV testing for minoritized people. We examined the relationship between race and infectious diseases (HIV, HCV, syphilis) testing in one Massachusetts jail, Middlesex House of Corrections (MHOC). This is a retrospective analysis of people incarcerated at MHOC who opted-in to infectious diseases testing between 2016-2020. Variables of interest were race/ethnicity, self-identified history of psychiatric illness, and ever having experienced restrictive housing. Twenty-three percent (1,688/8,467) of people who were incarcerated requested testing at intake. Of those, only 38% received testing. Black non-Hispanic (25%) and Hispanic people (30%) were more likely to request testing than white people (19%). Hispanic people (16%, AOR 1.69(1.24-2.29) were more likely to receive a test result compared to their white non-Hispanic (8%, AOR 1.54(1.10-2.15)) counterparts. Black non-Hispanic and Hispanic people were more likely to opt-in to and complete infectious disease testing than white people. These findings could be related to racial disparities in access to care in the community. Additionally, just over one-third of people who requested testing received it, underscoring that there is room for improvement in ensuring testing is completed. We hope our collaborative efforts with jail professionals can encourage other cross-disciplinary investigations.

Low frequency of allergy referral for penicillin allergy evaluation in an urban Boston primary care setting.

Background: A key strategy to combat the public health crisis of antimicrobial resistance is to use appropriate antibiotics, which is difficult in patients with a penicillin allergy label. Objective: Our aim was to investigate racial and ethnic differences related to penicillin allergy labeling and referral to allergy/immunology in primary care. Methods: This was a retrospective study of Tufts Medical Center's Boston-based primary care patients in 2019. Univariable and multivariable logistic regression models were used to examine demographic associations with (1) penicillin allergy label and (2) allergist referral. Results: Of 21,918 primary care patients, 2,391 (11%) had a penicillin allergy label; of these, 249 (10%) had an allergist referral. In multivariable logistic regression models, older age (adjusted odds ratio [aOR] = 1.06 [95% CI = 1.04-1.09]) and female sex (aOR = 1.58 [95% CI = 1.44-1.74]) were associated with higher odds of penicillin allergy label carriage. Black race (aOR = 0.77 [95% CI = 0.69-0.87]) and Asian race (aOR = 0.47 [95% CI = 0.41-0.53]) were associated with lower odds of penicillin allergy label carriage. In multivariable regression, allergist referral was associated with female sex (aOR = 1.52 [95% CI = 1.10-2.10]) and Black race (aOR = 1.74 [95% CI = 1.25-2.45]). Of 93 patients (37%) who completed their allergy visit, 26 (28%) had received penicillin allergy evaluation or were scheduled to receive a penicillin allergy evaluation at a future visit. Conclusions: There were racial differences in penicillin allergy labeling and referral. Allergy referral for penicillin allergy assessment was rare. Larger studies are needed to assess penicillin allergy labeling and delabeling with an equity focus on optimizing patient health outcomes.

Increased Mortality of Black Incarcerated and Hospitalized People: a Single State Cohort Analysis.

OBJECTIVE: To quantify racial disparities in mortality and post-hospitalization outcomes among incarcerated individuals that were hospitalized during their incarceration period. METHODS: We designed a retrospective cohort study using administrative and hospital data collected from a preferred healthcare referral center for all Massachusetts jails and prisons between January 2011 and December 2018 with linkage to Massachusetts Vital Records and Statistics. We identified 4260 incarcerated individuals with complete data on race/ethnicity that were hospitalized during the study period. The primary study indicators were age, race, ethnicity, length of hospital stay, Elixhauser comorbidity score, incarceration facility type, and number of hospital admissions. The primary outcome was time to death. RESULTS: Of the incarcerated individuals that were hospitalized, 2606 identified as White, 1214 identified as Black, and 411 people who identified as some other race. The hazard of death significantly increased by 3% (OR: 1.03; 95% CI: 1.02-1.03) for each additional yearly increase in age. After adjusting for the interaction between race and age, Black race was significantly associated with 3.01 increased hazard (95% CI: 1.75-5.19) of death for individuals hospitalized while incarcerated compared to White individuals hospitalized while incarcerated. Hispanic ethnicity and being incarcerated in a prison facility was not associated with time to mortality, while increased mean Elixhauser score (HR: 1.07; 95% CI: 1.06-1.08) and ≥ 3 hospital admissions (HR: 2.47; 95% CI: 2.07-2.95) increased the hazard of death. CONCLUSIONS: Our findings suggest disparities exist in the mortality outcomes among Black and White individuals who are hospitalized during incarceration, with an increased rate of death among Black individuals. Despite hypothesized equal access to healthcare within correctional facilities, our findings suggest that incarcerated and hospitalized Black individuals may experience worse disparities than their White counterparts, which has not been previously explored or reported in the literature. In addition to decarceration, advocacy, and political efforts, increased efforts to support research access to datasets of healthcare outcomes, including hospitalization and death, for incarcerated people should be encouraged. Further research is needed to identify and address the implicit and explicit sources of these racial health disparities across the spectrum of healthcare provision.

Racial Differences in Self-Report of Mental Illness and Mental Illness Treatment in the Community: An Analysis of Jail Intake Data.

Jails and prisons in the United States house people with elevated rates of mental health and substance use disorders. The goal of this cross-sectional study was to evaluate the frequency of racial/ethnic differences in the self-report of mental illness and psychiatric medication use at jail entry. Our sample included individuals who had been incarcerated between 2016 and 2020 at the Middlesex Jail & House of Correction, located in Billerica, MA. We used data from the "Offender Management System," the administrative database used by the jail containing data on people who are incarcerated, and COREMR, the electronic medical record (EMR) used in the Middlesex Jail & House of Correction. We evaluated two primary outcomes (1) self-reported mental illness history and (2) self-reported use of psychiatric medication, with the primary indicator of interest as race/ethnicity. At intake, over half (57%) of the sample self-reported history of mental illness and 20% reported the use of psychiatric medications. Among people who self-reported a history of mental illness, Hispanic (AOR: 0.73, 95% CI: 0.60-0.90), Black (AOR: 0.52, 95% CI: 0.43-0.64), Asian/Pacific Islander (Non-Hispanic) people (AOR: 0.31, 95% CI: 0.13-0.74), and people from other racial/ethnic groups (AOR: 0.33, 95% CI: 0.11-0.93) all had decreased odds of reporting psychiatric medications. Mental illness was reported in about one-half of people who entered jail, but only 20% reported receiving medications in the community prior to incarceration. Our findings build on the existing literature on jail-based mental illness and show racial disparities in self-report of psychiatric medications in people who self-reported mental illness. The timing, frequency, and equity of mental health services in both the community and the jail setting deserves further research, investment, and improvement.

Corrections Officers' and Sheriffs' Perceptions of COVID-19 Vaccine Operationalization.

Justice-involved populations are at an elevated risk for infectious disease transmission and have been profoundly negatively impacted by the COVID-19 pandemic. Vaccination is being utilized as a primary tool for prevention and protection from serious infection in carceral settings. We examined the barriers and facilitators to vaccine distribution by surveying key stakeholders-sheriffs and corrections officers-in these settings. Most respondents felt prepared for rollout, although they still identified significant barriers to operationalization of vaccine distribution. Barriers ranked highest by stakeholders were vaccine hesitancy and problems related to deficits in communication and planning. There is enormous opportunity to install practices that will address the significant barriers being faced to efficient vaccine distribution and amplify existing facilitators. These could include, for example, the incorporation of in-person community communication models for discussion of the vaccine (and hesitancy) in carceral facilities.

Barriers to severe acute respiratory coronavirus virus 2 (SARS-CoV-2) testing reported by healthcare workers during the first pandemic wave at an academic center in Boston, Massachusetts.

Healthcare workers (HCWs) experience barriers to severe acute respiratory coronavirus virus 2 (SARS-CoV-2) testing specific to their perceptions of access, and employment factors. A survey was sent to all employees at one Boston hospital to examine their perceived barriers to testing. HCWs who reported difficulty paying their bills were less likely to receive a SARS-CoV-2 test.

Racial and Ethnic Disparities in HIV Testing in People Who Use Drugs Admitted to a Tertiary Care Hospital.

Ending the HIV epidemic requires increased testing, diagnosis, and linkage to care. In the past 10 years, rates of HIV have increased among people with substance use disorder (SUD). HIV testing is recommended during hospitalization. Despite rising rates of infections and recommendations, HIV testing remains suboptimal. This study sought to detect differences in HIV testing by race and ethnicity in people who use drugs (PWUD) admitted to Tufts Medical Center (TuftsMC). This study is a retrospective review of hospitalized PWUD admitted from January 1, 2017 to December 31, 2020. PWUD were identified through toxicology results, medication prescribed for SUD, and nursing intake questions. The primary outcome of interest was whether an HIV test was ordered during hospitalization. The indicator of interest was race and ethnicity. Of 13,486 PWUD admitted to TuftsMC, only 10% had an HIV test ordered. Compared with White patients, Black patients [adjusted odds ratio (AOR): 0.69, 95% confidence interval (CI) (0.59-0.83)] and Hispanic patients [AOR: 0.68, 95% CI (0.55-0.84)] had decreased odds of receiving an HIV test. Our report is the first to show racial and ethnic differences in HIV testing ordering for hospitalized PWUD. Without access to harm reduction tools and expanded systems-based testing strategies, the HIV epidemic will continue and disproportionately impact minoritized communities.

The association of gender with receptive and distributive needle sharing among individuals who inject drugs.

BACKGROUND: Injection drug use and needle sharing remains a public health concern due to the associated risk of HIV, HCV and skin and soft tissue infections. Studies have shown gendered differences in the risk environment of injection drug use, but data are currently limited to smaller urban cohorts. METHODS: To assess the relationship between gender and needle sharing, we analyzed publicly available data from the 2010-2019 National Survey on Drug Use and Health (NSDUH) datasets. Chi-square tests were conducted for descriptive analyses and multivariable logistic regression models were built adjusting for survey year, age, HIV status, and needle source. RESULTS: Among the entire sample, 19.8% reported receptive needle sharing, 18.8% reported distributive sharing of their last needle, and 37.0% reported reuse of their own needle during last injection. In comparison with men, women had 34% increased odds (OR 1.34, 95% CI 1.11-1.55) of receptive needle sharing and 67% increased odds (OR 1.67, 95% CI 1.41-1.98) of distributive needle sharing. Reuse of one's own needle did not differ by gender. CONCLUSIONS: In this nationally representative sample, we found that women are more likely in comparison with men to share needles both through receptive and distributive means. Expansion of interventions, including syringe service programs, to increase access to sterile injection equipment is of great importance.

Implementing Health Related Social Needs Screening in an Outpatient Clinic.

INTRODUCTION/OBJECTIVES: Health-related social needs (HRSN) screening efforts have reported high rates of identified social needs. Little is known if efforts to conduct HRSN screening in resource-constrained federally-qualified health centers (FQHC) successfully captures a representative patient population. METHODS: This cross-sectional study extracted EMR data from 2016 to 2020 for 4731 screened patients from 7 affiliated clinics of a FQHC. Unscreened patients were pulled as a random sample from the study period. A multivariable logistic regression was used to identify sociodemographic traits, chronic disease diagnoses and burden, and clinic visit type and frequency associated with being screened for HRSN. RESULTS: BHC screened 4731 unique patients or <1% of the total clinic population. Screened patients had a median of 3.3 (±2.5) unmet HRSN. Medicaid patients had higher odds of being screened (aOR = 1.38, CI 1.19-1.61) relative to Medicare patients. The odds of being screened for social needs increased with more provider visits per year: compared to fewer than 1 visit per year, patients with 1 to 3 provider visits (aOR = 2.06, CI 1.73-2.32), 4 to 6 provider visits (aOR = 3.34, CI 2.89-3.87), and more than 6 provider visits (aOR = 5.16, CI 4.35-6.12) all had higher odds of social needs screening. Patients with a higher comorbid disease burden (>2 conditions, aOR = 2.80, CI 2.07-3.79) had higher odds of screening. CONCLUSIONS: Our findings demonstrate an increased likelihood to screen patients who visit outpatient services more often and have a higher comorbid disease burden. To meet state-level Medicaid requirements, resource-constrained FQHCs that implement clinic wide HRSN screening may be well served to identify a priori strategies to ensure representative and equitable screening across the patient population.

Association of Unmet Social Needs with Chronic Illness: A Cross-Sectional Study.

Screening for social needs during routine medical visits is increasingly common. To date, there are limited data on which social needs are most predictive of health outcomes. The aim of this study is to build a predictive model from integrated social needs screening and health data to identify individual or clusters of social needs that are predictive of chronic illnesses. Using the electronic medical record data from a Federally Qualified Health Center collected from January 2016 to December 2020, demographic, diagnosis, and social needs screening data were used to look at adjusted and unadjusted associations of individual unmet social needs with chronic illnesses (n = 2497). The least absolute shrinkage and selection operator (LASSO) model was used to identify which social need(s) were associated with overall burden of chronic illness, and individual diagnoses of hypertension, obesity, diabetes, and psychiatric illness. The LASSO model identified age, race, language, gender, insurance, transportation, and food insecurity as significant predictors of any chronic illness. Using these variables in a multivariable model, transportation (adjusted odds ratio [aOR] 1.66) was the only social need that remained significantly associated with chronic illness diagnosis. Transportation need was also significantly associated with diabetes (aOR 1.44) and psychiatric illness (aOR 1.98). Food insecurity was associated with obesity (aOR 10.21). Using LASSO models to identify significant social needs, transportation was identified as a predictor in 3 of the 5 models. Further research is warranted to evaluate if addressing patients' transportation needs has the potential to mitigate chronic disease sequelae for vulnerable adults to advance health equity.

Influenza Vaccination in Massachusetts Jails: A Mixed-Methods Analysis.

OBJECTIVES: Influenza infects millions of people each year and contributes to tens of thousands of deaths annually despite the availability of vaccines. People most at risk of influenza complications are disproportionately represented in people incarcerated in US prisons and jails. The objectives of this study were to survey health administrators in Massachusetts county jails about institutional influenza vaccine policies and practices and estimate influenza vaccination rates in Massachusetts jails from 2013 to 2020. METHODS: In April 2020, we administered surveys to the health services administrators in Massachusetts' 14 county jails to gather information about influenza vaccination policies and delivery practices. To calculate influenza vaccination rates for each facility, we obtained data on influenza vaccine orders from the Massachusetts Department of Public Health for each county in Massachusetts for influenza seasons 2013-2020. We calculated summary statistics for each reporting facility and each year, conducted a Kruskal-Wallis analysis to compare vaccination rates between years, and used a linear regression model to identify predictors of vaccination rates. RESULTS: Influenza vaccination rates in Massachusetts jails ranged from 1.9% to 11.8%. We found no significant differences in vaccination rates between years. Influenza vaccine ordering and delivery practices varied by jail, and respondents had high levels of confidence in influenza policies and vaccine delivery practices. CONCLUSIONS: Influenza vaccination rates in Massachusetts jails are low, and delivery practices in jails vary. Lack of influenza vaccinations in jails is a gap in health care that needs to be prioritized, especially considering the current COVID-19 pandemic. Further investigations for effective and equitable vaccination in this population should involve people who are incarcerated and people who make influenza vaccine policies in jails.

Hepatitis C Virus Is Associated With Increased Mortality Among Incarcerated Hospitalized Persons in Massachusetts.

Hepatitis C virus (HCV) is curable, but incarcerated populations face barriers to treatment. In a cohort of incarcerated hospitalized patients in Boston, Massachusetts, HCV infection was associated with increased mortality. Access to HCV treatment in carceral settings is crucial to avoid unnecessary death and to support HCV elimination efforts.

Healthcare workers' perspectives on coronavirus testing availability: a cross sectional survey.

BACKGROUND: Studies on the impact of the novel SARS-CoV-2 virus (COVID) for healthcare workers (HCWs) rarely include the full spectrum of hospital workers, including less visible patient support roles. In the early days of the pandemic, COVID testing was preferentially available to HCWs. The objective of this study was to understand how individual experiences for all HCWs during the pandemic were associated with perceptions of access to, and receipt of COVID testing . METHODS: All hospital employees (n = 6736) in a single academic medical center in Boston, Massachusetts were invited to participate in a cross-sectional survey regarding perceived access to, and receipt of COVID testing during the first wave of the pandemic (March - August 2020). Responses were linked to human resources data. Log binomial univariate and multivariable models were used to estimate associations between individual and employment variables and COVID testing. RESULTS: A total of 2543 employees responded to the survey (38 %). The mean age was 40 years (± 14). Respondents were female (76 %), white (55 %), worked as nurses (27 %), administrators (22 %) and patient support roles (22 %); 56 % of respondents wanted COVID testing. Age (RR 0.91, CI 0.88-0.93), full time status (RR 0.85, CI 0.79-0.92), employment tenure (RR 0.96, CI 0.94-0.98), changes in quality of life (RR 0.94, CI 0.91-0.96), changes in job duties (RR 1.19, CI 1.03-1.37), and worry about enough paid sick leave (RR 1.21, CI 1.12-1.30) were associated with interest in testing. Administrators (RR 0.64, CI 0.58-0.72) and patient support staff (RR 0.85, CI 0.78-0.92) were less likely than nurses to want testing. Age (RR 1.04, CI 1.01-1.07), material hardships (RR 0.87, CI 0.79-0.96), and employer sponsored insurance (RR 1.10, CI 1.00-1.22) were associated with receiving a COVID test. Among all employees, only administrative/facilities staff were less likely to receive COVID testing (RR 0.69, CI 0.59-0.79). CONCLUSIONS: This study adds to our understanding of how hospital employees view availability of COVID testing. Hazard pay or other supports for hospital workers may increase COVID testing rates. These findings may be applicable to perceived barriers towards vaccination receipt.

Increased HIV testing in people who use drugs hospitalized in the first wave of the COVID-19 pandemic.

People who use drugs (PWUD) often experience barriers to preventative health care. During the COVID-19 pandemic, due to lapses in harm reduction services, several public health experts forecasted subsequent increases in diagnosis of HIV in PWUD. As many inpatient hospitals reworked patient flow during the COVID-19 surge, we hypothesized that HIV testing in PWUD would decrease. To answer this question, we compiled a deidentified list of hospitalized patients with electronic medical record indicators of substance use-a positive urine toxicology screen, prescribed medications to treat opioid use disorder, a positive CIWA score, or a positive CAGE score-admitted between January, 2020 and August, 2020. The outcome of interest was HIV test completion during inpatient hospitalization. The study used logistic regression to examine associations between type of substance use and receipt of HIV test. The study grouped substance use type into four groups (1) opioids (oxycodone, fentanyl, or other opiates) or opioid use disorder treatments (methadone, buprenorphine, naltrexone); (2) stimulant use (cocaine or amphetamines); (3) alcohol use (presence of a positive CAGE or CIWA score or alcohol present on toxicology screen); and (4) benzodiazepine use (benzodiazepines present on toxicology screen). The proportion of PWUD who were tested for HIV increased from 10.4% in January, 2020 to 28.2% in April, 2020 and back down to 12% in August. Notably, there was an inverse trend over time for number of people hospitalized with drug use, from 259 in January to a nadir of 85 in April, and then up to 217 in August, 2020. Contrary to our hypothesis, HIV testing increased during the COVID-19 pandemic, and we discuss explanations for this finding. The decrease in HIV testing post-pandemic peak is a reminder that we must work to develop interventions that lead to sustained high rates of HIV testing for all people, and especially for PWUD.