Transforming Latinx HIV Care: Mixed-Methods Evaluation of a Patient-Centered HIV Practice Transformation.

We conducted a mixed-method longitudinal evaluation of an HIV primary care practice transformation project in Washington, D.C. The project aimed to enhance organizational capacity to deliver culturally appropriate and patient-centered care for Latinxs living with HIV. Quantitative and qualitative data were simultaneously collected to capture the complex interactions among care providers, staff, and patients as well as to monitor practice changes that occurred as a result of the project implementation. The practice transformation intervention consisted of core competency workforce training, workflow redesign, and data-driven quality improvement strategies utilized to guide the intervention and to gather data from providers and patients. The mixed-methods approach facilitated meaningful change within the clinic that resulted in improved patient outcomes, patient experiences of care, and increases in staff's perceived level of knowledge of patient-centered care and improved efficiencies in HIV health care service delivery.

Use of a State Registry to Compare Practices of Physicians and Nurse Practitioners in Completing Physician Orders for Life-Sustaining Treatment Forms.

Background: Understanding the role of nonphysicians in Physician Orders for Life-Sustaining Treatment (POLST) completion is limited. Objectives: To examine the role that nurse practitioners (NPs) play in POLST completion and differences between NPs and physicians in POLST orders. Design: Retrospective observational study. Setting/Subjects: A total of 3829 POLST forms submitted to the West Virginia (WV) e-Directive Registry between July 1, 2018 and June 30, 2019, which was completed by 98 NPs and 511 physicians. Measurements: POLST forms completed and orders in POLST Section A and Section B by all physicians and NPs according to practice (primary care, palliative care, hospital, and nursing home) and by palliative care physicians and NPs only. Results: NPs completed almost twice as many forms on average as physicians (9.54 ± 20.82 vs. 5.66 ± 17.18, p = 0.0064). NPs constituted 16.10% (98/609) of the clinicians writing POLST forms but completed 24.40% (935/3829) of the forms (p < 0.001). Compared with physicians' orders, a greater percentage of NP's orders was for do-not-resuscitate in Section A (87.20% vs. 72.60%, p < 0.001) and comfort measures in Section B (42.90% vs. 33.10%, p < 0.001). There was a greater percentage of NPs in palliative care practice than physicians (23.50% vs. 6.07%, p < 0.001), and palliative care NPs completed 64.20% (600/935) of the forms submitted by NPs compared with palliative care physicians who completed 17.90% (517/2894) of the forms submitted by physicians (p < 0.001). Conclusions: In WV, physician and NP POLST completion differs based on practice. NPs completed significantly more POLST forms on average and more often ordered comfort measures. NPs can play a significant role in POLST completion.

Role of chickpea flour in texturization of extruded pea protein.

A growing demand for alternative sources of texturized vegetable protein (TVP) has resulted from various factors including plant allergies, perceived health risks associated with genetically modified organisms (GMO), animal welfare beliefs, and lifestyle choices. Soy and wheat have been the primary ingredients in TVP over the past few decades, but desires for clean label ingredients (especially non-GMO and nonallergenic) have led to demand for alternative plant protein ingredients such as pea protein. To understand the capabilities of pea protein to create meat-like texture with additions of another protein source that also contributes starch, this study focused on extruding pea protein with increasing amounts of chickpea flour (CPF). Six treatments, with inclusions of CPF ranging from 0 to 50%, were processed on a twin-screw extruder to determine the optimal ratio of pea protein isolate to CPF. Bulk density was the greatest with 20% CPF (272 g/L) and resulted in the lowest water holding capacity (55.5%). Texture profile analysis (TPA) hardness, springiness, and chewiness showed optimum results for the 10 and 20% CPF (674 to 1024 g, 72.1 to 80.7%, 400 to 439, respectively). With no CPF addition, protein interactions created a strong network exhibiting extreme springiness (91.3%). Addition of CPF greater than 20% resulted in a detrimental decrease in hardness by 38 to 84% and chewiness by 73 to 92%. Phase transition analysis and specific mechanical energy data provided a greater understanding of the degree of texturization during extrusion. Inclusion of CPF between 10 and 20% led to the optimum protein to starch ratio, allowing adequate protein texturization and creating product characteristics that could potentially mimic meat. PRACTICAL APPLICATION: Pea protein was mixed with increasing levels of chickpea flour to produce a textured plant protein product using extrusion technology. The ratio of protein to starch can be optimized to target specific textural attributes of textured pea protein to closely mimic different meat products like fish, chicken, or beef. The 10 and 20% chickpea flour treatments produced the highest quality products according to textural attributes.

How COVID-19 Changed Advance Care Planning: Insights From the West Virginia Center for End-of-Life Care.

CONTEXT: Coronavirus disease 2019 (COVID-19) led to increased attention nationally on advance care planning. OBJECTIVES: To describe the impact COVID-19 had on advance care planning based on changes in the calls to the West Virginia Center for End-of-Life Care (center) and in the volume and types of documents requested from and submitted to the center and its e-Directive Registry (registry). METHODS: A retrospective and observational analysis between January 1, 2020 and June 30, 2020 of calls to the center; advance directives downloaded from the center's Web site as well as mailed to the public and medical orders mailed to health care professionals on request to the center; and advance directives and medical orders submitted to the registry. RESULTS: The nature of calls changed to COVID-19-related topics, including confirmation of forms on the registry, urgent desire to initiate advance care planning, temporary rescindment of treatment-limiting forms, and questions on how to honor patients' wishes in advance directives and medical orders in light of their COVID-19 status. Also in the first six months of 2020, the center distributed more advance directives than it had during the same months in the last five years and more medical orders than it had in the preceding four years when there were no revisions to the medical order forms required by changes to the state law. CONCLUSION: COVID-19 resulted in a new sense of urgency regarding advance care planning by West Virginians with increased attention to document their wishes and ensure that they were in the registry.

Required Sexual Orientation and Gender Identity Reporting by US Health Centers: First-Year Data.

Objectives. To assess the performance of US health centers during the first year of required sexual orientation and gender identity (SOGI) data reporting and to estimate the baseline proportion of lesbian, gay, bisexual, and transgender patients accessing health centers. Methods. We conducted a secondary analysis of SOGI data from 2016. These data were reported by 1367 US health centers caring for 25 860 296 patients in the United States and territories. Results. SOGI data were missing for 77.1% and 62.8% of patients, respectively. Among patients with data, 3.7% identified as lesbian, gay, bisexual, or something else; 0.4% identified as transgender male or female; 27.5% did not disclose their sexual orientation; and 9.3% did not disclose their gender identity. Conclusions. Although health centers had a high percentage of missing SOGI data in the first year of reporting, among those with data, the percentages of lesbian, gay, bisexual, and transgender people were similar to national estimates, and disclosure was more than 70%. Future data collection efforts would benefit from increased training for health centers and improved messaging on the clinical benefits of SOGI data collection and reporting.

Development and Implementation of an HIV Health Care Practice Transformation Model for Latinos.

A Latino Community Health Center in Washington, D.C. implemented and evaluated a practice transformative model to optimize human resources and improve quality health outcomes in HIV service delivery for Latino patients. We conducted a qualitative formative assessment through interviews and focus groups with clinic staff and patients living with HIV/AIDS in order to inform implementation. The formative assessment identified specific training and practice facilitation needs and provided valuable insight for choosing evaluation metrics. Incorporating staff input fostered staff engagement in laying the foundation of the transformation and helped build a sense of ownership of the transformative process. Through the formative assessment process we gained insight into the organization's HIV practice and improved our ability to align practice transformation goals with evaluation metrics to better measure changes resulting from the model implementation. The formative assessment process also highlighted challenges in conducting health systems research with Latino communities in the U.S.

The Association of Health Seeking Behaviors With Human Papillomavirus Vaccination Status Among High-Risk Urban Youth.

BACKGROUND: Vaccination is the primary strategy to reduce the burden of human papillomavirus (HPV) related diseases in the United States. Unvaccinated youth are at risk for HPV infection and associated diseases, and limited research has explored factors associated with HPV vaccination among those who are disadvantaged and at high risk, including lesbian, gay, bisexual, transgender and queer and/or homeless. METHODS: A retrospective electronic medical record review was conducted at an urban, homeless, and lesbian, gay, bisexual, transgender and queer focused health center in northeastern US logistic regression models examined the associations between HPV vaccination and demographic/social characteristics and health behaviors. RESULTS: A total of 1211 men and 1326 women (gender at birth) records were reviewed from patients (ages 13-26 years) who presented for care between January 2010 and June 2013. The sample was diverse, and about half identified as heterosexual and reported stable/secure housing. Approximately 8% of men and 29% of women had obtained ≥ 1 HPV vaccine dose. The strongest predictors of vaccine initiation were health-related behaviors: having an annual examination, obtaining a non-HPV vaccine, and engaging in oral sex. Additionally, for women only, having had a Pap test or a sexually transmitted infection visit were also associated with an increase in odds, whereas identifying as transmale decreased the odds of vaccination. Having private insurance was the only predictor of 3-dose completion (women only). CONCLUSIONS: Among a high-risk adolescent sample, primarily health-seeking behaviors increased the odds of HPV vaccination, reinforcing the importance of providers using various routine preventative visits as opportunities/cues to vaccine.

The Utility of a Syndemic Framework in Understanding Chronic Disease Management Among HIV-Infected and Type 2 Diabetic Men Who Have Sex with Men.

Syndemic theory posits that epidemics of multiple physical and psychosocial problems co-occur among disadvantaged groups due to adverse social conditions. Although sexual minority populations are often stigmatized and vulnerable to multiple health problems, the syndemic perspective has been underutilized in understanding chronic disease. To assess the potential utility of this perspective in understanding the management of co-occurring HIV and Type 2 diabetes, we used linear regression to examine glycemic control (A1c) among men who have sex with men (MSM) with both HIV and Type 2 diabetes (n = 88). Bivariable linear regression explored potential syndemic correlates of inadequate glycemic control. Compared to those with adequate glycemic control (A1c ≤ 7.5 %), more men with inadequate glycemic control (A1c > 7.5 %) had hypertension (70 vs. 46 %, p = 0.034), high triglycerides (93 vs. 61 %, p = 0.002), depression (67 vs. 39 %, p = 0.018), current substance abuse (15 vs. 2 %, p = 0.014), and detectable levels of HIV (i.e., viral load ≥75 copies per ml blood; 30 vs. 10 %, p = 0.019). In multivariable regression controlling for age, the factors that were independently associated with higher A1c were high triglycerides, substance use, and detectable HIV viral load, suggesting that chronic disease management among MSM is complex and challenging for patients and providers. Findings also suggest that syndemic theory can be a clarifying lens for understanding chronic disease management among sexual minority stigmatized populations. Interventions targeting single conditions may be inadequate when multiple conditions co-occur; thus, research using a syndemic framework may be helpful in identifying intervention strategies that target multiple co-occurring conditions.