Search

Background: New highly effective medications are available to treat the hepatitis C virus (HCV). However, little is known about HCV treatment knowledge and readiness among young people who inject drugs (PWID), or factors that may contribute to treatment uptake and adherence in this treatment era., Purpose: Using a framework for understanding healthcare utilization, we examined perspectives and experiences of young PWID tied to the HCV care continuum in Boston, Massachusetts, to inform future strategies., Methods: We conducted 24 in-depth interviews with active and recent PWID aged 22-30 years living with HCV in Boston, February-August 2016. At the time of the interviews, no participants had been prescribed or had taken the new direct acting antivirals. We developed a codebook deductively from the interview guide and coded and analyzed the data into themes using a consensus-based process., Results: The following five themes emerged, which captured PWID's knowledge of and experiences with HCV along the care continuum through social determinants of engagement in care, as well as illness level: (1) deservingness of HCV treatment and stigma, (2) dissatisfaction with provider interactions, (3) perceived lack of referral to treatment and care continuity, (4) disincentives around HCV treatment for PWID; and (5) perceived need for treatment. Young PWID living with HCV face unique barriers to HCV testing, counseling, and treatment., Conclusion: Breakdowns in the HCV care continuum may have adverse effects on HCV-treatment readiness and willingness. Improved public health and practice approaches are needed to address these barriers to effectively engage young PWID in care., (Copyright © 2018. Published by Elsevier B.V.)

Background and Objectives: Despite guidelines recommending shared decision making, nephrologists vary significantly in their approaches to discussing conservative management for kidney replacement therapy with older patients. Many older patients do not perceive dialysis initiation as a choice or receive sufficient information about conservative management for reasons incompletely understood. We examined how nephrologists' perceptions of key outcomes and successful versus failed treatment discussions shape their approach and characterized different models of decision making, patient engagement, and conservative management discussion., Design, Setting, Participants, & Measurements: Our qualitative study used semistructured interviews with a sample of purposively sampled nephrologists. Interviews were conducted from June 2016 to May 2017 and continued until thematic saturation. Data were analyzed using typological and thematic analyses., Results: Among 35 nephrologists from 18 practices, 20% were women, 66% had at least 10 years of nephrology experience, and 80% were from academic medical centers. Four distinct approaches to decision making emerged: paternalist, informative (patient led), interpretive (navigator), and institutionalist. Five themes characterized differences between these approaches, including patient autonomy, engagement and deliberation (disclosing all options, presenting options neutrally, eliciting patient values, and offering explicit treatment recommendation), influence of institutional norms, importance of clinical outcomes ( e.g. , survival and dialysis initiation), and physician role (educating patients, making decisions, pursuing active therapies, and managing symptoms). Paternalists and institutionalists viewed initiation of dialysis as a measure of success, whereas interpretive and informative nephrologists focused on patient engagement, quality of life, and aligning patient values with treatment. In this sample, only one third of providers presented conservative management to patients, all of whom followed either informative or interpretive approaches. The interpretive model best achieved shared decision making., Conclusions: Differences in nephrologists' perceptions of their role, patient autonomy, and successful versus unsuccessful encounters contribute to variation in decision making for patients with kidney disease., (Copyright © 2018 by the American Society of Nephrology.)

Background: Although dialysis may not provide a large survival benefit for older patients with kidney failure, few are informed about conservative management. Barriers and facilitators to discussions about conservative management and nephrologists' decisions to present the option of conservative management may vary within the nephrology provider community., Study Design: Interview study of nephrologists., Setting & Participants: National sample of US nephrologists sampled based on sex, years in practice, practice type, and region., Methodology: Qualitative semistructured interviews continued until thematic saturation., Analytical Approach: Thematic and narrative analysis of recorded and transcribed interviews., Results: Among 35 semistructured interviews with nephrologists from 18 practices, 37% described routinely discussing conservative management ("early adopters"). 5 themes and related subthemes reflected issues that influence nephrologists' decisions to discuss conservative management and their approaches to these discussions: struggling to define nephrologists' roles (determining treatment, instilling hope, and improving patient symptoms), circumventing end-of-life conversations (contending with prognostic uncertainty, fearing emotional backlash, jeopardizing relationships, and tailoring information), confronting institutional barriers (time constraints, care coordination, incentives for dialysis, and discomfort with varied conservative management approaches), conservative management as "no care," and moral distress. Nephrologists' approaches to conservative management discussions were shaped by perceptions of their roles and by a common view of conservative management as no care. Their willingness to pursue conservative management was influenced by provider- and institutional-level barriers and experiences with older patients who regretted or had been harmed by dialysis (moral distress). Early adopters routinely discussed conservative management as a way of relieving moral distress, whereas others who were more selective in discussing conservative management experienced greater distress., Limitations: Participants' views are likely most transferable to large academic medical centers, due to oversampling of academic clinicians., Conclusions: Our findings clarify how moral distress serves as a catalyst for conservative management discussion and highlight points of intervention and mechanisms potentially underlying low conservative management use in the United States., (Copyright © 2017 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: Between 2000 and 2012, the incident dialysis population in the United States increased by nearly 60%, most sharply among adults 75 years and older. End-of-life (EOL) conversations among dialysis patients are associated with better patient-centered outcomes and lower use of aggressive interventions in the last month of life. This study examined how health literacy may affect engagement, comprehension, and satisfaction with EOL conversations among elderly dialysis patients., Design and Methods: Qualitative/descriptive study with semi-structured interviews about health literacy, EOL conversations, and goals of care with 31 elderly dialysis patients at 2 centers in Boston. Themes were interpreted in the context of Nutbeam's health literacy framework., Results: Despite high mortality risk in this population, only 13% of patients had discussed EOL preferences with physicians, half had discussed EOL with their social network, and 25% of participants explicitly stated that they had never considered EOL preferences. Less than 30% of participants could correctly define terminology commonly used in EOL conversations. Analyses yielded 5 themes: (1) Misunderstanding EOL terminology; (2) Nephrologists reluctant to discuss EOL; (3) Patients conforming to socially constructed roles; (4) Discordant expectations and dialysis experiences; and (5) Reconciling EOL values and future care. Patients had limited understanding of EOL terminology, lacked of opportunities for meaningful EOL discussion with providers and family, resulting in uncertainty about future care., Implications: Limited health literacy presents a substantial barrier to communication and could lead to older adults committing to an intensive pattern of care without adequate information. Clinicians should consider health literacy when discussing dialysis initiation.

Although social support is used to determine transplant eligibility, the relationship between social support, medication adherence, and survival among transplant recipients remains unclear. We estimated the relationship between social support and post-transplant medication adherence and outcomes using 10 electronic databases from inception to January 2016. Study quality was assessed and all review stages were conducted independently by 2 reviewers. Systematic review and meta-analysis were conducted. Thirty-two studies (9102 participants) met inclusion criteria: 21 assessed medication adherence (5197 participants), and 13 assessed clinical outcomes (3905 participants). Among high quality studies, neither social support nor marital status was predictive of medication adherence or post-transplant outcomes. Social support was not associated with medication adherence. It was associated with superior post-transplant outcomes, but the relationship was not significant among high quality studies. Compared to unmarried recipients, married recipients were more likely to adhere to medication post-transplant, but this relationship was not significant among high quality studies. Marital status was not significantly associated with transplant success. Social support is weakly and inconsistently associated with post-transplant adherence and outcomes. Larger prospective studies using consistent and validated measures are needed to justify the use of inadequate social support as a contraindication to transplantation., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Although shared decision-making (SDM) can better align patient preferences with treatment, barriers remain incompletely understood and the impact on patient satisfaction is unknown., Methods: This is a qualitative study with semistructured interviews. A purposive sample of prevalent dialysis patients ≥65 years of age at two facilities in Greater Boston were selected for diversity in time from initiation, race, modality and vintage. A codebook was developed and interrater reliability was 89%. Codes were discussed and organized into themes., Results: A total of 31 interviews with 23 in-center hemodialysis patients, 1 home hemodialysis patient and 7 peritoneal dialysis patients were completed. The mean age was 76 ± 9 years. Two dominant themes (with related subthemes) emerged: decision-making experiences and satisfaction, and barriers to SDM. Subthemes included negative versus positive decision-making experiences, struggling for autonomy, being a 'good patient' and lack of choice. In spite of believing that dialysis initiation should be the patient's choice, no patients perceived that they had made a choice. Patients explained that this is due to the perception of imminent death or that the decision to start dialysis belonged to physicians. Clinicians and family frequently overrode patient preferences, with patient autonomy honored mostly to select dialysis modality. Poor decision-making experiences were associated with low treatment satisfaction., Conclusions: Despite recommendations for SDM, many older patients were unaware that dialysis initiation was voluntary, held mistaken beliefs about their prognosis and were not engaged in decision-making, resulting in poor satisfaction. Patients desired greater information, specifically focusing on the acuity of their choice, prognosis and goals of care., (© The Author 2016. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.)

Purpose of Review: Geographic variation in liver transplantation has been the subject of extensive scrutiny, reflecting concerns that location is unfairly determinative for people needing organ transplantation. Drawing upon a number of established ethical approaches, we examine whether geographic differences in access to livers are inherently unethical., Recent Findings: We posit that the ethical imperative for redistribution largely hinges upon the belief that access to organs systematically disadvantages certain identifiable groups of patients over others. Yet, our data suggest that regions likely to be net-contributors may suffer from less access to transplantation and other health services, fewer social protections and greater burden of liver disease. Drawing upon a number of ethical approaches, including strict egalitarianism, utilitarianism, Maximin, Reciprocity, Sen's Impartial Spectator and a health equity framework, we demonstrate that the current proposal has significant weaknesses, and may not achieve its goals of improving equity and efficiency., Summary: Formulating effective policies and programs to ameliorate health inequalities requires an understanding of the interrelated causes of mortality disparities and specific interventions to mitigate these causes. Although our analysis does not indicate how ethically distribute livers, but it suggests that this be done with consideration for population-based health measures.

Policy Points: The growing shortage of life-saving organs has reached unprecedented levels, with more than 120,000 Americans waiting for them. Despite national attempts to increase organ donation and federal laws mandating the equitable allocation of organs, geographic disparities remain. A better understanding of the contextual determinants of organ donor designation, including social capital, may enhance efforts to increase organ donation by raising the probability of collective action and fostering norms of reciprocity and cooperation while increasing costs to defectors. Because community-level factors, including social capital, predict more than half the variation in donor designation, future interventions should tailor strategies to specific communities as the unit of intervention., Context: The growing shortage of organs has reached unprecedented levels. Despite national attempts to increase donation and federal laws mandating the equitable allocation of organs, their availability and waiting times vary significantly nationwide. Organ donor designation is a collective action problem in public health, in which the regional organ supply and average waiting times are determined by the willingness of individuals to be listed as organ donors. Social capital increases the probability of collective action by fostering norms of reciprocity and cooperation while increasing costs to defectors. We examine whether social capital and other community-level factors explain geographic variation in organ donor designation rates in Massachusetts., Methods: We obtained a sample of 3,281,532 registered drivers in 2010 from the Massachusetts Department of Transportation Registry of Motor Vehicles (MassDOT RMV). We then geocoded the registry data, matched them to 4,466 census blocks, and linked them to the 2010 US Census, the American Community Survey (ACS), and other sources to obtain community-level sociodemographic, social capital (residential segregation, voter registration and participation, residential mobility, violent-death rate), and religious characteristics. We used spatial modeling, including lagged variables to account for the effect of adjacent block groups, and multivariate regression analysis to examine the relationship of social capital and community-level characteristics with organ donor designation rates., Findings: Block groups with higher levels of social capital, racial homogeneity, income, workforce participation, owner-occupied housing, native-born residents, and white residents had higher rates of organ donor designation (p < 0.001). These factors remained significant in the multivariate model, which explained more than half the geographic variance in organ donor designation (R(2) = 0.52)., Conclusions: The findings suggest that community-level factors, including social capital, predict more than half the variation in donor designation. Future interventions should target the community as the unit of intervention and should tailor messaging for areas with low social capital., (© 2015 Milbank Memorial Fund.)

Background: Currently, many transplantation centers do not follow former living kidney donors on a long-term basis. Several potential barriers have been identified to provide this follow-up of former living kidney donors, including concerns that donor insurance will not reimburse transplantation centers or primary care physicians for this care. Here, we report the rates at which different insurance companies reimbursed our transplantation center for follow-up visits of living donors., Methods: We collected data on all yearly follow-up visits of living donors billed from January 1, 2007, to December 31, 2010, representing 82 different donors. Concurrent visits of their recipients were available for 47 recipients and were used as a control group., Results: We find that most bills for follow-up visits of living kidney donors were paid by insurance companies, at a rate similar to the reimbursement for recipient follow-up care., Conclusions: Our findings suggest that, for former donors with insurance, inadequate reimbursement should not be a barrier in providing follow-up care.

Utilization rates of non-psychiatric health services are often higher in depressed compared to non-depressed adults. We examine whether these differences can be explained by the increased prevalence or the increased impact of demographic, socioeconomic, geographic, and health-related factors. The sample was taken from The Survey of Health, Ageing and Retirement in Europe (Wave 1 Release 2), a prospective observational study of 31,115 randomly selected people ages 50+ living in Austria, Germany, Sweden, the Netherlands, Spain, Italy, France, Denmark, Greece, Switzerland, Belgium, and Israel. Blinder-Oaxaca decomposition methods for multivariate linear regression models were used to estimate the influence of prevalence and impact of covariates on utilization among depressed and non-depressed participants. We find robust evidence that the gap in utilization between depressed and non-depressed can be accounted for by both prevalence (explained) and impact (unexplained) differences. The prevalence effect accounted for 57.7% whereas differences in the impact of covariates between depressed and non-depressed persons explained 42.3% of differences in utilization rates. Despite cross-national differences in quality and coverage of health services, in all countries, the prevalence effect was explained entirely by health measures, including: chronic diseases, functional mobility, painful symptoms, and self-reported health. The impact effect varied cross-nationally, but was largely explained by socioeconomic status and urbanicity. Hospitalization among depressed adults was twice that of non-depressed adults. Policies aimed at improving adherence and improving disease management among depressed adults should be explored.

Purpose: Socioeconomic inequality has been associated with higher levels of morbidity and mortality. This study explores the role of absolute and relative deprivation in predicting late-life depression on both individual and country levels., Design and Methods: Country- and individual-level inequality indicators were used in multivariate logistic regression and in relative indexes of inequality. Data obtained from the Survey of Health, Ageing and Retirement in Europe (SHARE, Wave 1, Release 2) included 22,777 men and women (aged 50-104 years) from 10 European countries. Late-life depression was measured using the EURO-D scale and corresponding clinical cut point. Absolute deprivation was measured using gross domestic product and median household income at the country level and socioeconomic status at the individual level. Relative deprivation was measured by Gini coefficients at the country level and educational attainment at the individual level., Results: Rates of depression ranged from 18.10% in Denmark to 36.84% in Spain reflecting a clear north-south gradient. Measures of absolute and relative deprivation were significant in predicting depression at both country and individual levels. Findings suggest that the adverse impact of societal inequality cannot be overcome by increased individual-level or country-level income. Increases in individual-level income did not mitigate the effect of country-level relative deprivation., Implications: Mental health disparities persist throughout later life whereby persons exposed to higher levels of country-level inequality suffer greater morbidity compared with those in countries with less inequality. Cross-national variation in the relationship between inequality and depression illuminates the need for further research.

One potential mechanism for reducing racial/ethnic disparities in the receipt of kidney transplants is to enhance minorities' pursuit of living donor kidney transplantation (LDKT). Pursuit of LDKT is influenced by patients' personal values, their extended social networks, the health care system, and the community at large. This review discusses research and interventions promoting LDKT, especially for minorities, including improving education for patients, donors, and providers, using LDKT kidneys more efficiently, and reducing surgical and financial barriers to transplant. Future directions to increase awareness of LDKT for more racial/ethnic minorities also are discussed including developing culturally tailored transplant education, clarifying transplant-eligibility practice guidelines, strengthening partnerships between community kidney providers and transplant centers, and conducting general media campaigns and community outreach., (Copyright (c) 2010 Elsevier Inc. All rights reserved.)

Objective: Assess influence of education and noneducation-based measures of socioeconomic status on depression, illuminating the cumulative and income-adjusted effects cross-nationally., Method: Cross-sectional study of 22,777 men and women (50 to 104 years) from 10 European countries. Individual-level data were collected from the Survey of Health, Ageing and Retirement in Europe (SHARE)., Results: Educational attainment was a strong predictor of late-life depression across all countries. Depression rates ranged from 18.10% in Denmark to 36.84% in Spain, reflecting a North- South gradient. Odds of depression were approximately twice as high among adults with less than a high school education compared with those of greater educational background (p < .001). Inverse association between educational attainment and depression remained significant independent of all other sociodemographic variables., Discussion: Socioeconomic disparities in depression persist throughout later life. Variation in impact of education on depression cross-nationally illuminates need for future research into the protective effects of early-life education.

This article presents a health lifestyle audience segmentation analysis based primarily on social cognitive theory. Two linked mail surveys were conducted among a representative group of US adults (N = 2967). Segmentation variables included data on five health behaviors (smoking, alcohol consumption, physical activity, nutrition and weight control), internal personal and social/ environmental variables associated with each of the health behaviors, as well as health value, sensation- seeking, life satisfaction and age. K-means classification analysis was employed; seven health lifestyles were identified. The majority of the health lifestyles are reliable, and as a whole, all demonstrate both discriminative, construct and predictive validity. The health-lifestyle audience segments are briefly profiled, and an argument is made that health- lifestyle segmentation, more than demographic or behavioral segmentation alone, can advance the goals of public health communication.