Clinical and Sociobehavioral Prediction Model of 30-Day Hospital Readmissions Among People With HIV and Substance Use Disorder: Beyond Electronic Health Record Data.

BACKGROUND: Under the Affordable Care Act, hospitals receive reduced reimbursements for excessive 30-day readmissions. However, the Centers for Medicare and Medicaid Services does not consider social and behavioral variables in expected readmission rate calculations, which may unfairly penalize systems caring for socially disadvantaged patients, including patients with HIV. SETTING: Randomized controlled trial of patient navigation with or without financial incentives in HIV-positive substance users recruited from the inpatient setting at 11 US hospitals. METHODS: External validation of an existing 30-day readmission prediction model, using variables available in the electronic health record (EHR-only model), in a new multicenter cohort of HIV-positive substance users was assessed by C-statistic and Hosmer-Lemeshow testing. A second model evaluated sociobehavioral factors in improving the prediction model (EHR-plus model) using multivariable regression and C-statistic with cross-validation. RESULTS: The mean age of the cohort was 44.1 years, and participants were predominantly males (67.4%), non-white (88.0%), and poor (62.8%, <$20,000/year). Overall, 17.5% individuals had a hospital readmission within 30 days of initial hospital discharge. The EHR-only model resulted in a C-statistic of 0.65 (95% confidence interval: 0.60 to 0.70). Inclusion of additional sociobehavioral variables, food insecurity and readiness for substance use treatment, in the EHR-plus model resulted in a C-statistic of 0.74 (0.71 after cross-validation, 95% confidence interval: 0.64 to 0.77). CONCLUSIONS: Incorporation of detailed social and behavioral variables substantially improved the performance of a 30-day readmission prediction model for hospitalized HIV-positive substance users. Our findings highlight the importance of social determinants in readmission risk and the need to ask about, adjust for, and address them.

Race/ethnicity, education, and age are associated with engagement in ecological momentary assessment text messaging among substance-using MSM in San Francisco.

BACKGROUND: Ecological momentary assessments (EMA) are data collection approaches that characterize behaviors in real-time. However, EMA is underutilized in alcohol and substance use research among men who have sex with men (MSM). The aim of this analysis is to explore the correlates of engagement in EMA text messages among substance-using MSM in San Francisco. METHODS: The present analysis uses data collected from the Project iN pilot study (n=30). Over a two-month period, participants received and responded to EMA daily text messages inquiring about their study medication, alcohol, and methamphetamine use. Baseline characteristics including demographics, alcohol use, and substance use were examined as potential correlates of engagement in EMA text messages in logistic regression and proportional hazards models. RESULTS: Participants had a 74% response rate to EMA text messages over the study period. MSM of color had significantly lower adjusted odds of responding to EMA texts 80% of the time or more, compared to white MSM (adjusted odds ratio=0.05, 95%CI=0.01-0.38). College-educated MSM had a lower adjusted hazard of week-long discontinuation in EMA texts (adjusted hazard ratio=0.12, 95%CI=0.02-0.63). Older MSM had a higher adjusted hazard of week-long discontinuation in EMA texts (adjusted hazard ratio=1.15, 95%CI=1.01-1.31). CONCLUSION: Differences in engagement in EMA text prompts were discovered for MSM with different racial/ethnic backgrounds, ages, and education levels. Substance use variables were not correlated with engagement in text messages, suggesting that EMA may be a useful research tool among actively substance-using MSM in San Francisco.

Feasibility, Acceptability, and Tolerability of Targeted Naltrexone for Nondependent Methamphetamine-Using and Binge-Drinking Men Who Have Sex with Men.

BACKGROUND: There are no effective pharmacologic strategies for nondependent methamphetamine (meth)-using and binge-drinking men who have sex with men (MSM) at high-risk for HIV. We sought to determine the feasibility of enrolling and retaining this population in a pharmacologic trial; the acceptability of pharmacotherapy study procedures; and the tolerability of targeted naltrexone versus placebo. METHODS: Thirty meth-using and binge-drinking MSM were randomly assigned 1:1 to 50 mg naltrexone or placebo for 8 weeks for targeted administration (ie, during craving or in anticipation of meth or alcohol use). Substance use counseling and behavioral assessments were conducted every 2 weeks. Medication use was measured using WisePill dispensers. RESULTS: Trial completion was 93%; visit completion rate was 95%. Mean weekly number of medication pills taken was 2.1 and was similar between arms. Participant satisfaction rate was 96%. There were neither serious adverse events nor differences in adverse event rates between arms. In exploratory intention-to-treat analyses, there were no differences in meth use and drinking. Naltrexone participants had greater reductions in serodiscordant receptive anal intercourse [incident rate ratio (IRR) = 0.15; 95% CI = 0.05 to 0.42] and serodiscordant condomless receptive anal intercourse (IRR = 0.11; 95% CI = 0.03 to 0.37), compared with placebo. In subgroup analyses among frequent meth users, naltrexone participants had greater reductions in meth-using days (IRR = 0.78; 95% CI = 0.62 to 0.99). In as-treated analyses, frequent study medication users in the naltrexone arm had greater reductions in binge drinking days (IRR = 0.72; 95% CI = 0.54 to 0.97). CONCLUSIONS: Targeted naltrexone is a feasible, acceptable, and tolerable intervention strategy for nondependent meth-using and binge-drinking MSM. Naltrexone was associated with significant sexual risk reductions; and for some individuals, naltrexone was associated with meth and binge-drinking reductions.

Effect of risk-reduction counseling with rapid HIV testing on risk of acquiring sexually transmitted infections: the AWARE randomized clinical trial.

IMPORTANCE: To increase human immunodeficiency virus (HIV) testing rates, many institutions and jurisdictions have revised policies to make the testing process rapid, simple, and routine. A major issue for testing scale-up efforts is the effectiveness of HIV risk-reduction counseling, which has historically been an integral part of the HIV testing process. OBJECTIVE: To assess the effect of brief patient-centered risk-reduction counseling at the time of a rapid HIV test on the subsequent acquisition of sexually transmitted infections (STIs). DESIGN, SETTING, AND PARTICIPANTS: From April to December 2010, Project AWARE randomized 5012 patients from 9 sexually transmitted disease (STD) clinics in the United States to receive either brief patient-centered HIV risk-reduction counseling with a rapid HIV test or the rapid HIV test with information only. Participants were assessed for multiple STIs at both baseline and 6-month follow-up. INTERVENTIONS: Participants randomized to counseling received individual patient-centered risk-reduction counseling based on an evidence-based model. The core elements included a focus on the patient's specific HIV/STI risk behavior and negotiation of realistic and achievable risk-reduction steps. All participants received a rapid HIV test. MAIN OUTCOMES AND MEASURES: The prespecified outcome was a composite end point of cumulative incidence of any of the measured STIs over 6 months. All participants were tested for Neisseria gonorrhoeae, Chlamydia trachomatis, Treponema pallidum (syphilis), herpes simplex virus 2, and HIV. Women were also tested for Trichomonas vaginalis. RESULTS: There was no significant difference in 6-month composite STI incidence by study group (adjusted risk ratio, 1.12; 95% CI, 0.94-1.33). There were 250 of 2039 incident cases (12.3%) in the counseling group and 226 of 2032 (11.1%) in the information-only group. CONCLUSION AND RELEVANCE: Risk-reduction counseling in conjunction with a rapid HIV test did not significantly affect STI acquisition among STD clinic patients, suggesting no added benefit from brief patient-centered risk-reduction counseling. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01154296.

Aripiprazole for the treatment of methamphetamine dependence: a randomized, double-blind, placebo-controlled trial.

AIMS: To test aripiprazole for efficacy in decreasing use in methamphetamine-dependent adults, compared to placebo. DESIGN: Participants were randomized to receive 12 weeks of aripiprazole or placebo, with a 3-month follow-up and a platform of weekly 30-minute substance abuse counseling. SETTING: The trial was conducted from January 2009 to March 2012 at the San Francisco Department of Public Health. PARTICIPANTS: Ninety actively using, methamphetamine-dependent, sexually active adults were recruited from community venues. MEASUREMENTS: The primary outcome was regression estimated reductions in weekly methamphetamine-positive urines. Secondary outcomes were study medication adherence [by self-report and medication event monitoring systems (MEMS)], sexual risk behavior and abstinence from methamphetamine. FINDINGS: Participant mean age was 38.7 years, 87.8% were male, 50.0% white, 18.9% African American, and 16.7% Latino. Eighty-three per cent of follow-up visits and final visits were completed. By intent-to-treat, participants assigned to aripiprazole had similar reductions in methamphetamine-positive urines as participants assigned to placebo [risk ratio (RR) 0.88, 95% confidence interval (CI): 0.66-1.19, P = 0.41]. Urine positivity declined from 73% (33 of 45 participants) to 45% (18 of 40) in the placebo arm and from 77% (34 of 44) to 44% (20 of 35) in the aripiprazole arm. Adherence by MEMS and self-report was 42 and 74%, respectively, with no significant difference between arms (MEMS P = 0.31; self-report P = 0.17). Most sexual risk behaviors declined similarly among participants in both arms (all P > 0.05). There were no serious adverse events related to study drug, although participants randomized to aripiprazole reported more akathisia, fatigue and drowsiness (P < 0.05). CONCLUSION: Compared with placebo, aripiprazole did not reduce methamphetamine use significantly among actively using, dependent adults.

Role of computed tomography in the evaluation of acute chest pain.

Chest pain is common and the initial clinical presentation is often nonspecific. The emergency physician faces the challenge of correctly identifying those patients with a life-threatening cause of chest pain while avoiding unnecessary hospital admissions. Three important life-threatening causes of chest pain are aortic dissection, pulmonary embolism, and acute coronary syndrome. Simple clinical tools should be applied to exclude these diagnoses and avoid CT whenever possible. A normal serum d-dimer measurement can safely exclude pulmonary embolism and aortic dissection, although elevated d-dimer levels are common and nonspecific. Promising markers for early myocardial ischemia have been described and should be developed further. CT provides a first-line imaging tool for aortic dissection and pulmonary embolism based on its wide availability, speed, and high level of diagnostic performance. Improvements in CT scanner technology now enable in-depth data on the coronary arteries. Although angiographic information is limited in its relation to physiologic lesion significance, coronary CT is used to safely diagnose or exclude coronary disease as a source of chest pain in emergency department patients. "Triple rule-out" protocols designed to simultaneously assess the aorta, pulmonary arteries, and coronary arteries are a compromise between dedicated protocols for each diagnosis. The diagnostic value and appropriate clinical use of these protocols remain to be shown by randomized, controlled, outcomes-based trials.