Medical Research Council of South Africa.

Dramatically improving therapy (no errors, cure for multiple organ failure, sepsis, and pulmonary embolus) in a modern trauma system would decrease trauma mortality by 13%. In contrast, more than half of all deaths are potentially preventable with preinjury behavioral changes. Injury prevention is critical to reducing deaths in the modern trauma system.

Background Maternal and neonatal mortality is high in Africa, but few large, prospective studies have been done to investigate the risk factors associated with these poor maternal and neonatal outcomes. Methods A 7-day, international, prospective, observational cohort study was done in patients having caesarean delivery in 183 hospitals across 22 countries in Africa. The inclusion criteria were all consecutive patients (aged ≥18 years) admitted to participating centres having elective and non-elective caesarean delivery during the 7-day study cohort period. To ensure a representative sample, each hospital had to provide data for 90% of the eligible patients during the recruitment week. The primary outcome was in-hospital maternal mortality and complications, which were assessed by local investigators. The study was registered on the South African National Health Research Database, number KZ_2015RP7_22, and on ClinicalTrials.gov, number NCT03044899. Findings Between February, 2016, and May, 2016, 3792 patients were recruited from hospitals across Africa. 3685 were included in the postoperative complications analysis (107 missing data) and 3684 were included in the maternal mortality analysis (108 missing data). These hospitals had a combined number of specialist surgeons, obstetricians, and anaesthetists totalling 0•7 per 100 000 population (IQR 0•2-2•0). Maternal mortality was 20 (0•5%) of 3684 patients (95% CI 0•3-0•8). Complications occurred in 633 (17•4%) of 3636 mothers (16•2-18•6), which were predominantly severe intraoperative and postoperative bleeding (136 [3•8%] of 3612 mothers). Maternal mortality was independently associated with a preoperative presentation of placenta praevia, placental abruption, ruptured uterus, antepartum haemorrhage (odds ratio 4•47 [95% CI 1•46-13•65]), and perioperative severe obstetric haemorrhage (5•87 [1•99-17•34]) or anaesthesia complications (11•47 (1•20-109•20]). Neonatal mortality was 153 (4•4%) of 3506 infants (95% CI 3•7-5•0). Interpretation Maternal mortality after caesarean delivery in Africa is 50 times higher than that of high-income countries and is driven by peripartum haemorrhage and anaesthesia complications. Neonatal mortality is double the global average. Early identification and appropriate management of mothers at risk of peripartum haemorrhage might improve maternal and neonatal outcomes in Africa.

Purpose: Hispanic women are less likely to be screened for breast cancer than non-Hispanic women, which contributes to the disproportionate prevalence of advanced-stage breast cancer in this population group. Patient navigation may be a promising approach to help women overcome the complexity of accessing multiple health care services related to breast cancer screening and treatment. The goal of this study is to assess patient perception and cost-effectiveness of a multilevel, community-based patient navigation program to improve breast cancer screening among Hispanic women in South Texas. Methods: We used mixed methods—including focus groups of program participants and a microsimulation model of breast cancer—to evaluate the effectiveness and cost-effectiveness of the program on the target population. Program data from 2013 to 2016 were collected and used to conduct the analyses. Results: Focus groups showed that the patient navigation program improved patient knowledge, attitudes, and behaviors regarding breast health and increased the mammography screening rate from 60% to 80%. Cost-effectiveness analysis showed that the program could increase life expectancy by 0.71 years and yield an incremental cost-effectiveness ratio of $3120 per quality-adjusted life year compared to no intervention. Conclusion: The 3-year multilevel, community-based patient navigation program effectively increased mammography screening uptake and adherence and improved knowledge and behaviors on breast health among program participants. Future research is needed to translate and disseminate the program to other socioeconomic and demographic groups to test its robustness and design.

Although Hispanic men are at higher risk of developing colon cancer compared to non-Hispanic white men, colonoscopy screening among Hispanic men is much lower than among non-Hispanic white men. University Health System (UHS) in San Antonio, Texas, instituted a Colorectal Cancer Male Navigation (CCMN) Program in 2011 specifically designed for Hispanic men. The CCMN Program contacted 461 Hispanic men 50 years of age and older to participate over a 2-year period. Of these age-eligible men, 370 were screened for CRC after being contacted by the navigator. Using participant and program data, a Markov model was constructed to determine the cost-effectiveness of the CCMN Program. An average 50-year-old Hispanic male who participates in the CCMN Program will have 0.3 more quality-adjusted life-years (QALYs) compared to a similar male receiving usual care. Life expectancy is also predicted to increase by 6 months for participants compared to non-participants. The program results in net health care savings of $1,148 per participant ($424,760 for the 370 CCMN Program participants). The incremental cost-effectiveness ratio is estimated at $3,765 per QALY in favor of the navigation program. Interventions to reduce disparities in CRC screening across ethnic groups are needed, and this is one of the first studies to evaluate the economic benefit of a patient navigator program specifically designed for an urban population of Hispanic men. A colorectal cancer screening intervention which relies on patient navigators trained to address the unique needs of the targeted population (language barriers, transportation and scheduling assistance, colon cancer, and screening knowledge) can substantially increase the likelihood of screening and improve quality of life in a cost-effective manner.

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BACKGROUND/OBJECTIVE The US Preventive Services Task Force recommends 1‐time hepatitis C virus (HCV) screening of all baby boomers (born 1945–1965). However, little is known about optimal ways to implement HCV screening, counseling, and linkage to care. We developed strategies following approaches used for HIV to implement baby boomer HCV screening in a hospital setting and report results as well as costs. DESIGN/PATIENTS Prospective cohort of 6140 baby boomers admitted to a safety‐net hospital in South Texas from December 1, 2012 to January 31, 2014 and followed to December 10, 2014. PROCEDURES/MEASUREMENTS The HCV screening program included clinician/staff education, electronic medical record algorithm for eligibility and order entry, opt‐out consent, anti‐HCV antibody test with reflex HCV RNA, personalized inpatient counseling, and outpatient case management. Outcomes were anti‐HCV antibody‐positive and HCV RNA–positive results. RESULTS Of 3168 eligible patients, 240 (7.6%) were anti‐HCV positive, which was more likely (P < 0.05) for younger age, men, and uninsured. Of 214 (89.2%) patients tested for HCV RNA, 134 (4.2% of all screened) were positive (chronic HCV). Among patients with chronic HCV, 129 (96.3%) were counseled, 108 (80.6%) received follow‐up primary care, and 52 (38.8%) received hepatology care. Five patients initiated anti‐HCV therapy. Total costs for start‐up and implementation for 14 months were $286,482. CONCLUSIONS This inpatient HCV screening program diagnosed chronic HCV infection in 4.2% of tested patients and linked >80% to follow‐up care. Yet access to therapy is challenging for largely uninsured populations, and most programmatic costs of the program are not currently covered. Journal of Hospital Medicine 2015;10:510–516. © 2015 Society of Hospital Medicine

Low-income populations are disproportionately affected by hepatitis C virus (HCV) infection. Thus, implementing baby boomer screening (born 1945-1965) for HCV may be a high priority for safety net hospitals. We report the prevalence and predictors of HCV infection and advanced fibrosis or cirrhosis based on the Fibrosis-4 score plus imaging for a baby boomer cohort admitted to a safety net hospital over a 21-month interval with >9 months of follow-up. Anti-HCV antibody testing was performed for 4582, or 90%, of all neverscreened patients, of whom 312 (6.7%) tested positive. Adjusted odds ratios of testing anti-HCV-positive were 2.66 for men versus women (P < 0.001), 1.25 for uninsured versus insured (P 5 0.06), 0.70 for Hispanics versus non-Hispanic whites (P 5 0.005), and 0.93 per year of age (P < 0.001). Among 287 patients tested for HCV RNA (91% of all anti-HCVpositive cases), 175 (61%) were viremic (3.8% overall prevalence in cohort), which was 5% less likely per year of age (P < 0.03). Noninvasive staging of 148 (84.6%) chronic HCV patients identified advanced fibrosis or cirrhosis in 50 (33.8%), with higher adjusted odds ratios of 3.21 for Hispanics versus non-Hispanic whites/Asians (P 5 0.02) and 1.18 per year of age (P 5 0.001). Other factors associated with significantly higher adjusted odds ratios of advanced fibrosis or cirrhosis were alcohol abuse/dependence, obesity, and being uninsured. Conclusion: In this low-income, hospitalized cohort, 4% of 4582 screened baby boomers were diagnosed with chronic HCV, nearly twice the rate in the community; one-third had noninvasive testing that indicated advanced fibrosis or cirrhosis, which was significantly more likely for Hispanics, those of older age, those with obesity, those with alcohol abuse/ dependence, and those who lacked insurance. (HEPATOLOGY 2015;62:1388-1395