Central City Concern

BackgroundThe rate of hepatitis C virus (HCV) treatment initiation and cure is suboptimal among people experiencing homelessness. A recent randomized controlled trial conducted by our study team compared peer-assisted telemedicine for HCV (TeleHCV) to peer-assisted referral to local providers (enhanced usual care [EUC]) in a rural population in Oregon. We hypothesized that the TeleHCV treatment model is more effective than EUC among those with unstable housing.MethodsIn this secondary analysis of the Oregon TeleHCV randomized controlled trial in adults with HCV and injection drug use (n = 203), we explored the role of unstable housing as an effect modifier of the TeleHCV intervention using a Poisson regression analysis. Randomized arm, frequency of peer contacts, and medication lockers were exposures of interest. HCV cure, defined as undetectable HCV RNA 12 weeks after treatment initiation, is the primary outcome.ResultsOverall, attaining HCV cure was less likely for those with unstable housing (RR = 0.68, 0.49–0.96, p = 0.026). However, unstably housed participants assigned to the TeleHCV arm were more than 6 times more likely to achieve HCV cure compared to unstably housed EUC participants (RR = 6.47, 3.12–13.43, p < 0.001) with a statistically significant interaction between treatment assignment and housing status (p = 0.022). The impact of TeleHCV on HCV cure was also identified among stably housed participants, but with a smaller effect size (RR = 2.15, 1.19–3.89, p = 0.012). Among participants with unstable housing, greater peer engagement was associated with an increased likelihood of both treatment initiation (RR = 1.24, p < 0.001) and HCV cure (RR 1.26; p < 0.001).ConclusionsThe peer-assisted TeleHCV intervention was substantially more effective for achieving HCV cure among participants with unstable housing at baseline compared to those unstably housed who received EUC. The treatment model should be broadly disseminated to target populations with HCV and high rates of homelessness to achieve HCV elimination goals.Clinical trials registrationNCT04798521.

The Symptom Impact Questionnaire (SIQR), now used for over a decade, has strong psychometric properties based on patients' subjective questionnaire data and correlations with other general measures of severity. However, the construct validity of the SIQR in assessing the central features of fibromyalgia (FM) has not been tested specifically with more objective measures. This study examined the construct validity of the SIQR using clinical examination of prominent features of FM, as well as patient questionnaire data. We determined if SIQR severity groups (low, moderate, high severity) in 158 chronic pain patients (50 FM, 108 Pain/No FM) predicted four central features of FM tenderness and pain: digital palpation tenderness, blood pressure cuff evoked pain, widespread pain locations, and a persistent deep ache question. Low, moderate, and high SIQR severity groups showed concomitant increases in tenderness in response to digital evoked palpation (F=23.5; p<0.0000; ηp2=0.23; MR=.54), blood pressure cuff evoked pain (F=17.0; p<0.0000; ηp2=0.18; MR=0.48) and number of pain location (F=38.8; p<0.0000; ηp2=0.33; MR.59). Strongest differences in SIQR severity were found in response to the question, "I have a persistent deep aching over most of my body" (F=87.5; p<0.0000; ηp2=0.53; MR=0.74). The SIQR strongly predicts the central features of FM tenderness and pain including its widespreadness and its multifaceted character. We propose that tenderness, both locally and over most of the body, attendant to the SIQR is the hallmark of the FM phenotype: tenderness is focal, diffuse, deep, and superficial.

High-need high-cost (HNHC) patients consume a large proportion of health resources but often receive suboptimal care in traditional primary care. Intensive ambulatory care interventions attempt to better meet these patients' needs, but we know little about how teams delivering these interventions in clinics serving socially complex patient populations perceive their work. We performed a qualitative study of multidisciplinary staff experiences at a Federally Qualified Health Center (FQHC) caring for predominantly homeless HNHC patients in the context of an ongoing implementation of an ambulatory intensive care unit (A-ICU) intervention. We conducted semistructured interviews with 9 ambulatory intensive care team members and 6 "usual care" members. We conducted a thematic analysis, using an inductive approach, at a semantic level. Staff viewed complexity as a combination of social, behavioral, and medical challenges that lead to patient-health care system mismatch. Staff perceive the following as key ingredients in caring for HNHC patients: addressing both psychosocial and clinical needs together; persistence in staying connected to patients through chaotic periods; shared commitment and cohesion among interdisciplinary team members; and flexibility to tailor care to patients' individual situations. Participants' definitions of success focused more on improving patient engagement than reducing utilization or cost. FQHC staff working with HNHC patients perceive mismatch between the health care system and patients' clinical and social needs as the key driver of poor outcomes for these patients. Intensive ambulatory care teams may bridge mismatch through provision of psychosocial supports, flexible care delivery, and fostering team cohesion to support patient engagement.

The Recovery Association Project (RAP) is a nonprofit organization dedicated to creating a vehicle for people in recovery in the Portland, Oregon, metropolitan area to speak out and challenge the stigma on substance abuse–related issues. RAP's goals are to develop leadership among people in recovery and to support individual recovery through a range of peer-to-peer recovery support services. Core values and principles of RAP include the following beliefs: (1) active citizenship is a stage of recovery—it helps to end the social marginalization that is often involved with a history of addiction; (2) collectively in recovery, we can do together what we could not do alone; and (3) attainment of self-respect, integrity, and development of one's personal gifts is critical to one's recovery. From 2003 to 2007, RAP's Recovery Community Services Program (RCSP)-funded peer recovery services included a recovery center with a drop-in resource center, a wide range of clean-and-sober social and recreational activities, and numerous self-help meetings; a café located in the recovery center that served as a job training program for peers; and leadership training for civic engagement of people in recovery. The feedback RAP gathered from the Government Performance Reporting Act survey of participants during its RCSP grant, and from additional satisfaction questions RAP added to the survey, showed that RAP's services are meeting the needs of participants and helping sustain recovery. At the 6-month follow-up point, more than 85% of participants in RAP services indicated that they had not used alcohol or drugs in the past 30 days.