Exemplar Hospital initiation trial to Enhance Treatment Engagement (EXHIT ENTRE): protocol for CTN-0098B a randomized implementation study to support hospitals in caring for patients with opioid use disorder.

BACKGROUND: Hospitalizations involving opioid use disorder (OUD) are increasing. Medications for opioid use disorder (MOUD) reduce mortality and acute care utilization. Hospitalization is a reachable moment for initiating MOUD and arranging for ongoing MOUD engagement following hospital discharge. Despite existing quality metrics for MOUD initiation and engagement, few hospitals provide hospital based opioid treatment (HBOT). This protocol describes a cluster-randomized hybrid type-2 implementation study comparing low-intensity and high-intensity implementation support strategies to help community hospitals implement HBOT. METHODS: Four state implementation hubs with expertise in initiating HBOT programs will provide implementation support to 24 community hospitals (6 hospitals/hub) interested in starting HBOT. Community hospitals will be randomized to 24-months of either a low-intensity intervention (distribution of an HBOT best-practice manual, a lecture series based on the manual, referral to publicly available resources, and on-demand technical assistance) or a high-intensity intervention (the low-intensity intervention plus funding for a hospital HBOT champion and regular practice facilitation sessions with an expert hub). The primary efficacy outcome, adapted from the National Committee on Quality Assurance, is the proportion of patients engaged in MOUD 34-days following hospital discharge. Secondary and exploratory outcomes include acute care utilization, non-fatal overdose, death, MOUD engagement at various time points, hospital length of stay, and discharges against medical advice. Primary, secondary, and exploratory outcomes will be derived from state Medicaid data. Implementation outcomes, barriers, and facilitators are assessed via longitudinal surveys, qualitative interviews, practice facilitation contact logs, and HBOT sustainability metrics. We hypothesize that the proportion of patients receiving care at hospitals randomized to the high-intensity arm will have greater MOUD engagement following hospital discharge. DISCUSSION: Initiation of MOUD during hospitalization improves MOUD engagement post hospitalization. Few studies, however, have tested different implementation strategies on HBOT uptake, outcome, and sustainability and only one to date has tested implementation of a specific type of HBOT (addiction consultation services). This cluster-randomized study comparing different intensities of HBOT implementation support will inform hospitals and policymakers in identifying effective strategies for promoting HBOT dissemination and adoption in community hospitals. TRIAL REGISTRATION: NCT04921787.

Modeling the risk of aquatic species invasion spread through boater movements and river connections.

Aquatic invasive species (AIS) are one of the greatest threats to the functioning of aquatic ecosystems worldwide. Once an invasive species has been introduced to a new region, many governments develop management strategies to reduce further spread. Nevertheless, managing AIS in a new region is challenging because of the vast areas that need protection and limited resources. Spatial heterogeneity in invasion risk is driven by environmental suitability and propagule pressure, which can be used to prioritize locations for surveillance and intervention activities. To better understand invasion risk across aquatic landscapes, we developed a simulation model to estimate the likelihood of a waterbody becoming invaded with an AIS. The model included waterbodies connected via a multilayer network that included boater movements and hydrological connections. In a case study of Minnesota, we used zebra mussels (Dreissena polymorpha) and starry stonewort (Nitellopsis obtusa) as model species. We simulated the impacts of management scenarios developed by stakeholders and created a decision-support tool available through an online application provided as part of the AIS Explorer dashboard. Our baseline model revealed that 89% of new zebra mussel invasions and 84% of new starry stonewort invasions occurred through boater movements, establishing it as a primary pathway of spread and offering insights beyond risk estimates generated by traditional environmental suitability models alone. Our results highlight the critical role of interventions applied to boater movements to reduce AIS dispersal.

Modelo del riesgo de la invasión de especies acuáticas dispersadas por movimiento de botes y conexiones entre ríos Resumen Las especies acuáticas invasoras (EAI) son una de las principales amenazas para el funcionamiento de los ecosistemas acuáticos a nivel mundial. Una vez que una especie invasora ha sido introducida a una nueva región, muchos gobiernos desarrollan estrategias de manejo para disminuir la dispersión. Sin embargo, el manejo de las especies acuáticas invasoras en una nueva región se complica debido a las amplias áreas que necesitan protección y los recursos limitados. La heterogeneidad espacial de un riesgo de invasión es causada por la idoneidad ambiental y la presión de propágulo, que puede usarse para priorizar la ubicación de las actividades de vigilancia e intervención. Desarrollamos una simulación para estimar la probabilidad de que un cuerpo de agua sea invadido por EAI para tener un mejor entendimiento del riesgo de invasión en los paisajes acuáticos. El modelo incluyó cuencas conectadas a través de una red multicapa que incluía movimiento de botes y conexiones hidrológicas. Usamos como especies modelo a Dreissena polymorpha y a Nitellopsis obtusa en un estudio de caso en Minnesota. Simulamos el impacto de los escenarios de manejo desarrollado por los actores y creamos una herramienta de decisiones por medio de una aplicación en línea proporcionada como parte del tablero del Explorer de EAI. Nuestro modelo de línea base reveló que el 89% de las invasiones nuevas de D. polymorpha y el 84% de las de N. obtusa ocurrieron debido al movimiento de los botes, lo que lo estableció como una vía primaria de dispersión y nos proporcionó información más allá de las estimaciones de riesgo generadas por los modelos tradicionales de idoneidad ambiental. Nuestros resultados resaltan el papel crítico de las intervenciones aplicadas al movimiento de los botes para reducir la dispersión de especies acuáticas invasoras.

Adaptive COVID-19 Mitigation Strategies: Tradeoffs between Trigger Thresholds, Response Timing, and Effectiveness.

Background. To support proactive decision making during the COVID-19 pandemic, mathematical models have been leveraged to identify surveillance indicator thresholds at which strengthening nonpharmaceutical interventions (NPIs) is necessary to protect health care capacity. Understanding tradeoffs between different adaptive COVID-19 response components is important when designing strategies that balance public preference and public health goals. Methods. We considered 3 components of an adaptive COVID-19 response: 1) the threshold at which to implement the NPI, 2) the time needed to implement the NPI, and 3) the effectiveness of the NPI. Using a compartmental model of SARS-CoV-2 transmission calibrated to Minnesota state data, we evaluated different adaptive policies in terms of the peak number of hospitalizations and the time spent with the NPI in force. Scenarios were compared with a reference strategy, in which an NPI with an 80% contact reduction was triggered when new weekly hospitalizations surpassed 8 per 100,000 population, with a 7-day implementation period. Assumptions were varied in sensitivity analysis. Results. All adaptive response scenarios substantially reduced peak hospitalizations relative to no response. Among adaptive response scenarios, slower NPI implementation resulted in somewhat higher peak hospitalization and a longer time spent under the NPIs than the reference scenario. A stronger NPI response resulted in slightly less time with the NPIs in place and smaller hospitalization peak. A higher trigger threshold resulted in greater peak hospitalizations with little reduction in the length of time under the NPIs. Conclusions. An adaptive NPI response can substantially reduce infection circulation and prevent health care capacity from being exceeded. However, population preferences as well as the feasibility and timeliness of compliance with reenacting NPIs should inform response design. Highlights: This study uses a mathematical model to compare different adaptive nonpharmaceutical intervention (NPI) strategies for COVID-19 management across 3 dimensions: threshold when the NPI should be implemented, time it takes to implement the NPI, and the effectiveness of the NPI.All adaptive NPI response scenarios considered substantially reduced peak hospitalizations compared with no response.Slower NPI implementation results in a somewhat higher peak hospitalization and longer time spent with the NPI in place but may make an adaptive strategy more feasible by allowing the population sufficient time to prepare for changing restrictions.A stronger, more effective NPI response results in a modest reduction in the time spent under the NPIs and slightly lower peak hospitalizations.A higher threshold for triggering the NPI delays the time at which the NPI starts but results in a higher peak hospitalization and does not substantially reduce the time the NPI remains in force.

Diagnosed Gonorrhea Among Privately Insured Women: Analysis of United States Claims Data.

Background: Gonorrhea incidence in the United States has risen by nearly 50% in the last decade, while screening rates have increased. Gonorrhea sequelae rates could indicate whether increased gonorrhea incidence is due to better screening. We estimated the association of gonorrhea diagnosis with pelvic inflammatory disease (PID), ectopic pregnancy (EP), and tubal factor infertility (TFI) in women and detected changes in associations over time. Materials and Methods: This retrospective cohort study included 5,553,506 women aged 18-49 tested for gonorrhea in the IBM MarketScan claims administrative database from 2013-2018 in the United States. We estimated incidence rates and hazard ratios (HRs) of gonorrhea diagnosis for each outcome, adjusting for potential confounders using Cox proportional hazards models. We tested the interaction between gonorrhea diagnosis and the initial gonorrhea test year to identify changes in associations over time. Results: We identified 32,729 women with a gonorrhea diagnosis (mean follow-up time in years: PID = 1.73, EP = 1.75, TFI = 1.76). A total of 131,500 women were diagnosed with PID, 64,225 had EP, and 41,507 had TFI. Women with gonorrhea diagnoses had greater incidence per 1000 person-years for all outcomes (PID = 33.5, EP = 9.4, TFI = 5.3) compared to women without gonorrhea diagnoses (PID = 13.9, EP = 6.7, TFI = 4.3). After adjustment, HRs were higher in women with a gonorrhea diagnosis vs. those without [PID = 2.29 (95% confidence interval, CI: 2.15-2.44), EP = 1.57, (95% CI: 1.41-1.76), TFI = 1.70 (95% CI: 1.47-1.97)]. The interaction of gonorrhea diagnosis and test year was not significant, indicating no change in relationship by initial test year. Conclusion: The relationship between gonorrhea and reproductive outcomes has persisted, suggesting a higher disease burden.

Quantifying social contact patterns in Minnesota during stay-at-home social distancing order.

SARS-CoV-2 is primarily transmitted through person-to-person contacts. It is important to collect information on age-specific contact patterns because SARS-CoV-2 susceptibility, transmission, and morbidity vary by age. To reduce the risk of infection, social distancing measures have been implemented. Social contact data, which identify who has contact with whom especially by age and place are needed to identify high-risk groups and serve to inform the design of non-pharmaceutical interventions. We estimated and used negative binomial regression to compare the number of daily contacts during the first round (April-May 2020) of the Minnesota Social Contact Study, based on respondent's age, gender, race/ethnicity, region, and other demographic characteristics. We used information on the age and location of contacts to generate age-structured contact matrices. Finally, we compared the age-structured contact matrices during the stay-at-home order to pre-pandemic matrices. During the state-wide stay-home order, the mean daily number of contacts was 5.7. We found significant variation in contacts by age, gender, race, and region. Adults between 40 and 50 years had the highest number of contacts. The way race/ethnicity was coded influenced patterns between groups. Respondents living in Black households (which includes many White respondents living in inter-racial households with black family members) had 2.7 more contacts than respondents in White households; we did not find this same pattern when we focused on individual's reported race/ethnicity. Asian or Pacific Islander respondents or in API households had approximately the same number of contacts as respondents in White households. Respondents in Hispanic households had approximately two fewer contacts compared to White households, likewise Hispanic respondents had three fewer contacts than White respondents. Most contacts were with other individuals in the same age group. Compared to the pre-pandemic period, the biggest declines occurred in contacts between children, and contacts between those over 60 with those below 60.

The illusion of personal health decisions for infectious disease management: disease spread in social contact networks.

Close contacts between individuals provide opportunities for the transmission of diseases, including COVID-19. While individuals take part in many different types of interactions, including those with classmates, co-workers and household members, it is the conglomeration of all of these interactions that produces the complex social contact network interconnecting individuals across the population. Thus, while an individual might decide their own risk tolerance in response to a threat of infection, the consequences of such decisions are rarely so confined, propagating far beyond any one person. We assess the effect of different population-level risk-tolerance regimes, population structure in the form of age and household-size distributions, and different interaction types on epidemic spread in plausible human contact networks to gain insight into how contact network structure affects pathogen spread through a population. In particular, we find that behavioural changes by vulnerable individuals in isolation are insufficient to reduce those individuals' infection risk and that population structure can have varied and counteracting effects on epidemic outcomes. The relative impact of each interaction type was contingent on assumptions underlying contact network construction, stressing the importance of empirical validation. Taken together, these results promote a nuanced understanding of disease spread on contact networks, with implications for public health strategies.

Barriers, opportunities, and potential costs of expanding HIV support services.

Experiencing housing instability, food insecurity, and financial stress can negatively impact retention in care and treatment adherence for people living with HIV. Expanding services that support socioeconomic needs could help improve HIV outcomes. Our objective was to investigate barriers, opportunities, and costs of expanding socioeconomic support programs. Semi-structured interviews were conducted with organizations serving U.S. Ryan White HIV/AIDS Program clients. Costs were estimated from interviews, organization documents, and city-specific wages. Organizations reported complex patient, organization, program, and system challenges as well as several opportunities for expansion. The average one-year per-person cost for engaging new clients was $196 for transportation, $612 for financial aid, $650 for food aid, and $2498 for short-term housing (2020 USD). Understanding potential expansion costs is important for funders and local stakeholders. This study provides a sense of magnitude for costs to scale-up programs to better meet socioeconomic needs of low-income patients living with HIV.

Evaluation of Strategies to Improve Uptake of Expedited Partner Therapy for Chlamydia trachomatis Treatment in Minnesota: A Decision Analytic Model.

Background. Despite the established effectiveness of expedited partner therapy (EPT) in partner treatment of bacterial sexually transmitted infections (STI), the practice is underutilized. Objective. To estimate the relative effectiveness of strategies to increase EPT uptake (numbers of partners treated for chlamydia). Methods. We developed a care cascade model of cumulative probabilities to estimate the number of partners treated under strategies to increase EPT uptake in Minnesota. The care cascade model used data from clinical trials, population-based studies, and Minnesota chlamydia surveillance as well as in-depth interviews of health providers who regularly treat STI patients and a statewide survey of health providers across Minnesota. Results. Several strategies could improve EPT uptake among providers, including facilitating treatment payment (additional 1,932 partners treated) and implementing electronic health record reminders (additional 1,755 partners treated). Addressing concerns about liability would have the greatest effect, resulting in 2,187 additional partners treated. Conclusions. Providers expressed openness to offering EPT under several scenarios, which reflect differences in knowledge about EPT, its legality, and potential risks to patients. While addressing concerns about provider liability would have the greatest effect on number of partners treated, provider education and procedural changes could make a substantial impact. Highlights: Addressing provider concerns about expedited partner therapy (EPT) legality and its potential risks would result in the most partners treated for chlamydia.EPT alerts and electronic EPT prescriptions may also streamline partner treatment.Provider education about the legality of EPT and its potential risks and training in counseling patients on EPT could also increase uptake.

Longitudinal Trajectories of Alcohol Use in Vietnamese Adults with Hazardous Alcohol Use and HIV.

A three-armed drinking cessation trial in Vietnam found that both a brief and intensive version of an intervention effectively reduced hazardous drinking in people living with HIV. We used group-based trajectory modeling (GBTM) to assess the extent to which findings may vary by latent subgroups distinguished by their unique responses to the intervention. Using data on drinking patterns collected over the 12 months, GBTM identified five trajectory groups, three of which were suboptimal ["non-response" (17.2%); "non-sustained response" (15.7%), "slow response" (13.1%)] and two optimal ["abstinent" (36.4%); "fast response" (17.6%)]. Multinomial logistic regression was used to determine that those randomized to any intervention arm were less likely to be in a suboptimal trajectory group, even more so if randomized to the brief (vs. intensive) intervention. Older age and higher baseline coping skills protected against membership in suboptimal trajectory groups; higher scores for readiness to quit drinking were predictive of it. GBTM revealed substantial heterogeneity in participants' response to a cessation intervention and may help identify subgroups who may benefit from more specialized services within the context of the larger intervention.

An Introductory Tutorial on Cohort State-Transition Models in R Using a Cost-Effectiveness Analysis Example.

Decision models can combine information from different sources to simulate the long-term consequences of alternative strategies in the presence of uncertainty. A cohort state-transition model (cSTM) is a decision model commonly used in medical decision making to simulate the transitions of a hypothetical cohort among various health states over time. This tutorial focuses on time-independent cSTM, in which transition probabilities among health states remain constant over time. We implement time-independent cSTM in R, an open-source mathematical and statistical programming language. We illustrate time-independent cSTMs using a previously published decision model, calculate costs and effectiveness outcomes, and conduct a cost-effectiveness analysis of multiple strategies, including a probabilistic sensitivity analysis. We provide open-source code in R to facilitate wider adoption. In a second, more advanced tutorial, we illustrate time-dependent cSTMs.

Predicting the onset of hypertension for workers: does including work characteristics improve risk predictive accuracy?

Despite extensive evidence of work as a key social determinant of hypertension, risk prediction equations incorporating this information are lacking. Such limitations hinder clinicians' ability to tailor patient care and comprehensively address hypertension risk factors. This study examined whether including work characteristics in hypertension risk equations improves their predictive accuracy. Using occupation ratings from the Occupational Information Network database, we measured job demand, job control, and supportiveness of supervisors and coworkers for occupations in the United States economy. We linked these occupation-based measures with the employment status and health data of participants in the Coronary Artery Risk Development in Young Adults (CARDIA) study. We fit logistic regression equations to estimate the probability of hypertension onset in five years among CARDIA participants with and without variables reflecting work characteristics. Based on the Harrell's c- and Hosmer-Lemeshow's goodness-of-fit statistics, we found that our logistic regression models that include work characteristics predict hypertension onset more accurately than those that do not incorporate these variables. We also found that the models that rely on occupation-based measures predict hypertension onset more accurately for White than Black participants, even after accounting for a sample size difference. Including other aspects of work, such as workers' experience in the workplace, and other social determinants of health in risk equations may eliminate this discrepancy. Overall, our study showed that clinicians should examine workers' work-related characteristics to tailor hypertension care plans appropriately.

Variation in local Ryan White HIV/AIDS program service use and impacts on viral suppression: informing quality improvement efforts.

The U.S. Ryan White HIV/AIDS Program (RWHAP) funds comprehensive services for people living with HIV to support viral suppression (VS). We analyzed five years of RWHAP data from the Minneapolis-St. Paul region to (1) assess variation and (2) evaluate the causal effect of each RWHAP service on sustained VS by race/ethnicity. Sixteen medical and support services were included. Descriptive analyses assessed service use and trends over time. Causal analyses used generalized estimating equations and propensity scores to adjust for the probability of service use. Receipt of AIDS Drug Assistance Program and financial aid consistently showed higher probabilities of sustained VS, while food aid and transportation aid had positive impacts on VS at higher levels of service encounters; however, the impact of services could vary by race/ethnicity. For example, financial aid increased the probability of sustained VS by at least 3 percentage points for white, Hispanic and Black/African American clients, but only 1.6 points for Black/African-born clients. This study found that services addressing socioeconomic needs typically had positive impacts on viral suppression, yet service use and impact of services often varied by race/ethnicity. This highlights a need to ensure these services are designed and delivered in ways that equitably serve all clients.

A Tutorial on Time-Dependent Cohort State-Transition Models in R Using a Cost-Effectiveness Analysis Example.

In an introductory tutorial, we illustrated building cohort state-transition models (cSTMs) in R, where the state transition probabilities were constant over time. However, in practice, many cSTMs require transitions, rewards, or both to vary over time (time dependent). This tutorial illustrates adding 2 types of time dependence using a previously published cost-effectiveness analysis of multiple strategies as an example. The first is simulation-time dependence, which allows for the transition probabilities to vary as a function of time as measured since the start of the simulation (e.g., varying probability of death as the cohort ages). The second is state-residence time dependence, allowing for history by tracking the time spent in any particular health state using tunnel states. We use these time-dependent cSTMs to conduct cost-effectiveness and probabilistic sensitivity analyses. We also obtain various epidemiological outcomes of interest from the outputs generated from the cSTM, such as survival probability and disease prevalence, often used for model calibration and validation. We present the mathematical notation first, followed by the R code to execute the calculations. The full R code is provided in a public code repository for broader implementation.

The Role of HIV Partner Services in the Modern Biomedical HIV Prevention Era: A Network Modeling Study.

BACKGROUND: HIV partner services can accelerate the use of antiretroviral-based HIV prevention tools (antiretroviral therapy [ART] and preexposure prophylaxis [PrEP]), but its population impact on long-term HIV incidence reduction is challenging to quantify with traditional partner services metrics of partner identified or HIV screened. Understanding the role of partner services within the portfolio of HIV prevention interventions, including using it to efficiently deliver antiretrovirals, is needed to achieve HIV prevention targets. METHODS: We used a stochastic network model of HIV/sexually transmitted infection transmission for men who have sex with men, calibrated to surveillance-based estimates in the Atlanta area, a jurisdiction with high HIV burden and suboptimal partner services uptake. Model scenarios varied successful delivery of partner services cascade steps (newly diagnosed "index" patient and partner identification, partner HIV screening, and linkage or reengagement of partners in PrEP or ART care) individually and jointly. RESULTS: At current levels observed in Atlanta, removal of HIV partner services had minimal impact on 10-year cumulative HIV incidence, as did improving a single partner services step while holding the others constant. These changes did not sufficiently impact overall PrEP or ART coverage to reduce HIV transmission. If all index patients and partners were identified, maximizing partner HIV screening, partner PrEP provision, partner ART linkage, and partner ART reengagement would avert 6%, 11%, 5%, and 18% of infections, respectively. Realistic improvements in partner identification and service delivery were estimated to avert 2% to 8% of infections, depending on the combination of improvements. CONCLUSIONS: Achieving optimal HIV prevention with partner services depends on pairing improvements in index patient and partner identification with maximal delivery of HIV screening, ART, and PrEP to partners if indicated. Improving the identification steps without improvement to antiretroviral service delivery steps, or vice versa, is projected to result in negligible population HIV prevention benefit.

A Statewide Mixed-Methods Study of Provider Knowledge and Behavior Administering Expedited Partner Therapy for Chlamydia and Gonorrhea.

BACKGROUND: Expedited partner therapy (EPT) refers to the practice of having patients diagnosed with chlamydia or gonorrhea deliver medication directly to their partner(s) to treat them presumptively for infection. Although EPT facilitates timely treatment and prevents reinfection, it remains underused. We used findings from key informant interviews to design and implement a statewide survey to estimate knowledge and utilization of EPT and to identify barriers and facilitators to EPT among Minnesota providers. METHODS: From November to December 2020, we carried out 15 interviews with health providers who currently provide EPT and coded interviews by recurring themes. We then conducted a statewide online survey on sexually transmitted infection treatment and barriers to EPT, from December 2020 to March 2021. We disseminated the survey to all licensed Minnesota health providers, and those who reported treating bacterial sexually transmitted infections in the past year were included in the study. RESULTS: Interview themes included the importance of direct provision of partner medication, administrative/pharmacy barriers to treatment, inclusive EPT eligibility, and patient counseling. Of the 623 health providers who completed the online survey, only 70% thought EPT was legal and only 37% currently offer EPT. Of those who did not provide EPT, 78% said they would under certain circumstances. Barriers included concerns about safety/liability of prescribing without a medical examination, administrative concerns about prescriptions, and patient acceptance. CONCLUSIONS: Given that over a quarter of respondents did not know expedited partner therapy (EPT)'s legal status, improving provider education may increase EPT provision. More research is needed on system-level barriers and patient acceptance of solutions identified in this study.

Optimal timing and effectiveness of COVID-19 outbreak responses in China: a modelling study.

BACKGROUND: In January 2020, an outbreak of atypical pneumonia caused by a novel coronavirus, SARS-CoV-2, was reported in Wuhan, China. On Jan 23, 2020, the Chinese government instituted mitigation strategies to control spread. Most modeling studies have focused on projecting epidemiological outcomes throughout the pandemic. However, the impact and optimal timing of different mitigation approaches have not been well-studied. METHODS: We developed a mathematical model reflecting SARS-CoV-2 transmission dynamics in an age-stratified population. The model simulates health and economic outcomes from Dec 1, 2019 through Mar 31, 2020 for cities including Wuhan, Chongqing, Beijing, and Shanghai in China. We considered differences in timing and duration of three mitigation strategies in the early phase of the epidemic: city-wide quarantine on Wuhan, travel history screening and isolation of travelers from Wuhan to other Chinese cities, and general social distancing. RESULTS: Our model estimated that implementing all three mitigation strategies one week earlier would have averted 35% of deaths in Wuhan (50% in other cities) with a 7% increase in economic impacts (16-18% in other cities). One week's delay in mitigation strategy initiation was estimated to decrease economic cost by the same amount, but with 35% more deaths in Wuhan and more than 80% more deaths in the other cities. Of the three mitigation approaches, infections and deaths increased most rapidly if initiation of social distancing was delayed. Furthermore, social distancing of working-age adults was most critical to reducing COVID-19 outcomes versus social distancing among children and/or the elderly. CONCLUSIONS: Optimizing the timing of epidemic mitigation strategies is paramount and involves weighing trade-offs between preventing infections and deaths and incurring immense economic impacts. City-wide quarantine was not as effective as city-wide social distancing due to its much higher daily cost than social distancing. Under typical economic evaluation standards, the optimal timing for the full set of control measures would have been much later than Jan 23, 2020 (status quo).

Occupational Segregation And Hypertension Inequity: The Implication Of The Inverse Hazard Law Among Healthcare Workers.

In the United States (US), Black-particularly Black female-healthcare workers are more likely to hold occupations with high job demand, low job control with limited support from supervisors or coworkers and are more vulnerable to job loss than their white counterparts. These work-related factors increase the risk of hypertension. This study examines the extent to which occupational segregation explains the persistent racial inequity in hypertension in the healthcare workforce and the potential health impact of workforce desegregation policies. We simulated a US healthcare workforce with four occupational classes: health diagnosing professionals (i.e., highest status), health treating professionals, healthcare technicians, and healthcare aides (i.e., lowest status). We simulated occupational segregation by allocating 25-year-old workers to occupational classes with the race- and gender-specific probabilities estimated from the American Community Survey data. Our model used occupational class attributes and workers' health behaviors to predict hypertension over a 40-year career. We tracked the hypertension prevalence and the Black-white prevalence gap among the simulated workers under the staus quo condition (occupational segregation) and the experimental conditions in which occupational segregation was eliminated. We found that the Black-white hypertension prevalence gap became approximately one percentage point smaller in the experimental than in the status quo conditions. These findings suggest that policies designed to desegregate the healthcare workforce may reduce racial health inequities in this population. Our microsimulation may be used in future research to compare various desegregation policies as they may affect workers' health differently. Supplementary Information: The online version contains supplementary material available at 10.1007/s41996-022-00098-5.

Cost-effectiveness of Fecal Microbiota Transplantation for First Recurrent Clostridioides difficile Infection.

BACKGROUND: Both the American College of Gastroenterology and the Infectious Diseases Society of America (IDSA)/Society for Healthcare Epidemiology of America 2021 Clostridioides difficile infection (CDI) guidelines recommend fecal microbiota transplantation (FMT) for persons with multiple recurrent CDI. Emerging data suggest that FMT may have high cure rates when used for first recurrent CDI. The aim of this study was to assess the cost-effectiveness of FMT for first recurrent CDI. METHODS: We developed a Markov model to simulate a cohort of patients presenting with initial CDI infection. The model estimated the costs, effectiveness, and cost-effectiveness of different CDI treatment regimens recommended in the 2021 IDSA guidelines, with the additional option of FMT for first recurrent CDI. The model includes stratification by the severity of initial infection, estimates of cure, recurrence, and mortality. Data sources were taken from IDSA guidelines and published literature on treatment outcomes. Outcome measures were quality-adjusted life-years (QALYs), costs, and incremental cost-effectiveness ratios (ICERs). RESULTS: When FMT is available for first recurrent CDI, the optimal cost-effective treatment strategy is fidaxomicin for initial nonsevere CDI, vancomycin for initial severe CDI, and FMT for first and subsequent recurrent CDI, with an ICER of $27 135/QALY. In probabilistic sensitivity analysis at a $100 000 cost-effectiveness threshold, FMT for first and subsequent CDI recurrence was cost-effective 90% of the time given parameter uncertainty. CONCLUSIONS: FMT is a cost-effective strategy for first recurrent CDI. Prospective evaluation of FMT for first recurrent CDI is warranted to determine the efficacy and risk of recurrence.

Reevaluating the Evidence for Intensive Postoperative Extracolonic Surveillance for Nonmetastatic Colorectal Cancer.

OBJECTIVES: The FACS, GILDA, and COLOFOL trials have cast doubt on the value of intensive extracolonic surveillance for resected nonmetastatic colorectal cancer and by extension metastasectomy. We reexamined this pessimistic interpretation. We evaluate an alternative explanation: insufficient power to detect a realistically sized survival benefit that may be clinically meaningful. METHODS: A microsimulation model of postdiagnosis colorectal cancer was constructed assuming an empirically plausible efficacy for metastasectomy and thus surveillance. The model was used to predict the large-sample mortality reduction expected for each trial and the implied statistical power. A potential recurrence imbalance in the FACS trial was investigated. Goodness of fit between model predictions and trial results were evaluated. Downstream life expectancy was estimated and power calculations performed for future trials evaluating surveillance and metastasectomy. RESULTS: For all 3 trials, the model predicted a mortality reduction of ≤5% and power of <10%. The FACS recurrence imbalance likely led to a large relative bias (>2.5) in the hazard ratio for overall survival favoring control. After adjustment, both COLOFOL and FACS results were consistent with model predictions (P>.5). A 2.6 (95% credible interval 0.5-5.1) and 3.6 (95% credible interval 0.8-7.0) month increase in life expectancy is predicted comparing intensive extracolonic surveillance-routine computed tomography scans and carcinoembryonic antigen assays-with 1 computed tomography scan at 12 months or no surveillance, respectively. An adequately sized surveillance trial is not feasible. A metastasectomy trial should randomize at least 200 to 300 patients. CONCLUSIONS: Recent trial results do not warrant de novo skepticism of metastasectomy nor targeted extracolonic surveillance. Given the potential for clinically meaningful life-expectancy gain and significant uncertainty, a trial of metastasectomy is needed.