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[This corrects the article DOI: 10.3389/frhs.2022.958743.].

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OBJECTIVE: To estimate differences in scheduled and completed specialty referrals by race, ethnicity, language for care, and insurance type. STUDY DESIGN: We studied a retrospective cohort of 38 334 specialty referrals to a large children's hospital between March 2019 and March 2021. We included referrals for patients with primary care clinics within 5 miles of the hospital. We examined whether the odds of and time to scheduled and completed referrals differed by patient sociodemographic characteristics. RESULTS: Of all referrals, 62% were scheduled and 54% were completed. Referral completion rates were lower for patients with Black race (45%), Native Hawaiian/Pacific Islander race (48%), Spanish language (49%), and public insurance (47%). Odds of scheduled and completed referral were lower for Asian (aOR scheduled: 0.94, [95% CI: 0.89, 0.99]; aOR completed: 0.92 [0.87, 0.97]), Black (aOR scheduled: 0.86 [0.79, 0.94]; aOR completed: 0.80 [0.73, 0.87]), and publicly insured patients (aOR scheduled: 0.71 [0.66, 0.75]; aOR completed: 0.70 [0.66, 0.75]). Time to scheduled and completed referral was longer for Black (adjusted hazard ratio [aHR] scheduled: 0.93 [0.88, 0.98]; aHR completed: 0.93 [0.87, 0.99]) and publicly insured patients (aHR scheduled: 0.85 [0.82, 0.88]; aHR completed: 0.84 [0.80, 0.87]) and families with a language other than English (aHR scheduled: 0.66 [0.62, 0.70]; aHR completed: 0.92 [0.86, 0.99]). CONCLUSIONS: Within a geographically homogenous pediatric population, the odds and time to scheduled and completed specialty referrals differed by sociodemographic characteristics, suggesting the effects of discrimination. To improve access equity, health care organizations need clear and consistent referral workflows and more comprehensive metrics for access.

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BACKGROUND: The United States Virgin Islands (USVI) Department of Health (DOH) conducted a second Zika health brigade (ZHB) in 2021 to provide recommended Zika-related pediatric health screenings, including vision, hearing, neurologic, and developmental screenings, for children in the USVI. This was replicated after the success of the first ZHB in 2018, which provided recommended Zika-related pediatric health screenings to 88 infants and children exposed to Zika virus (ZIKV) during pregnancy. METHODS: Ten specialty pediatric care providers were recruited and traveled to the USVI to conduct the screenings. USVI DOH scheduled appointments for children included in CDC's U.S. Zika Pregnancy and Infant Registry (USZPIR). During the ZHB, participants were examined by pediatric ophthalmologists, pediatric audiologists, and pediatric neurologists. We report the percentage of participants who were referred for additional follow-up care or given follow-up recommendations in the 2021 ZHB and compare these referrals and recommendations to those given in the 2018 ZHB. RESULTS: Thirty-three children born to mothers with laboratory evidence of ZIKV infection during pregnancy completed screenings at the 2021 ZHB, of which 15 (45%) children were referred for additional follow-up care. Ophthalmological screenings resulted in the highest number of new referrals for a specialty provider among ZHB participants, with 6 (18%) children receiving referrals for that specialty. Speech therapy was the most common therapy referral, with 10 (30%) children referred, of which 9 (90%) were among those who attended the 2018 ZHB. CONCLUSIONS: Thirty-three children in a jurisdiction with reduced access to healthcare specialists received recommended Zika-related pediatric health screenings at the ZHB. New and continuing medical and developmental concerns were identified and appropriate referrals for follow-up care and services were provided. The ZHB model was successful in creating connections to health services not previously received by the participants.

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BACKGROUND: Substantial data from high-income countries support early interventions in the form of evidence-based Coordinated Specialty Care (CSC) for people experiencing First Episode Psychosis (FEP) to ameliorate symptoms and minimize disability. Chile is unique among Latin American countries in providing universal access to FEP services through a national FEP policy that mandates the identification of FEP individuals in primary care and guarantees delivery of community-based FEP treatments within a public health care system. Nonetheless, previous research has documented that FEP services currently provided at mental health clinics do not provide evidence-based approaches. This proposal aims to address this shortfall by first adapting OnTrackNY (OTNY), a CSC program currently being implemented across the USA, into OnTrackChile (OTCH), and then examine its effectiveness and implementation in Chile. METHODS: The Dynamic Adaptation Process will be used first to inform the adaptation and implementation of OTCH to the Chilean context. Then, a Hybrid Type 1 trial design will test its effectiveness and cost and evaluate its implementation using a cluster-randomized controlled trial (RCT) (N = 300 from 21 outpatient clinics). The OTCH program will be offered in half of these outpatient clinics to individuals ages 15-35. Usual care services will continue to be offered at the other clinics. Given the current COVID-19 pandemic, most research and intervention procedures will be conducted remotely. The study will engage participants over the course of 2 years, with assessments administered at enrollment, 12 months, and 24 months. Primary outcomes include implementation (fidelity, acceptability, and uptake) and service outcomes (person-centeredness, adherence, and retention). Secondary outcomes comprise participant-level outcomes such as symptoms, functioning, and recovery orientation. Over the course of the study, interviews and focus groups with stakeholders will be conducted to better understand the implementation of OTCH. DISCUSSION: Findings from this study will help determine the feasibility, effectiveness, and cost for delivering CSC services in Chile. Lessons learned about facilitators and barriers related to the implementation of the model could help inform the approach needed for these services to be further expanded throughout Latin America. TRIAL REGISTRATION: www. CLINICALTRIALS: gov NCT04247711 . Registered 30 January 2020. TRIAL STATUS: The OTCH trial is currently recruiting participants. Recruitment started on March 1, 2021, and is expected to be completed by December 1, 2022. This is the first version of this protocol (5/12/2021).

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Background: In 2005, Chile became the first country in Latin America to guarantee universal free access for the diagnosis and treatment of schizophrenia. A cluster randomized control trial utilizing the Dynamic Adaptation Process framework is underway to adapt and test the OnTrack coordinated specialty care model to provide recovery-oriented, person-centered care by a multidisciplinary team for individuals with first episode psychosis (FEP) in Chile. Methods: A qualitative formative research study was conducted to inform the initial adaptation of the OnTrack Chile (OTCH) program. We conducted key informant interviews (n = 17) with various stakeholders (policymakers; directors/managers of community mental health centers; mental health professionals) and focus group discussions (n = 6) with individuals with FEP and caregivers (n = 35 focus group participants total). Data was analyzed using thematic analysis, organized by participants' perspectives on the benefits, barriers, and recommendations for the key principles, multidisciplinary team, psychosocial components, and the training and supervision model of OnTrack. Results: Participants expressed enthusiasm and support for OnTrack's recovery-oriented and person-centered principles of care. While many participants lauded the emphasis on shared decision-making and family involvement, some reported reticence, citing that it is culturally normative for patients and families to adopt a passive role in treatment. Peer specialists, and the family psychoeducation and support and supported education and employment components were perceived as aspects that could encourage the promotion of personhood and autonomy development. However, implementation challenges, including the prevailing biomedical approach, professional hierarchy, and the lack of infrastructure, human, and financial resources necessitate some modifications to these aspects. Some mental health professionals further conveyed reservations regarding the perceived hierarchical structure of the supervision model. Conclusion: OnTrack represents a shift from a biomedical model to a valued, aspirational, person-centered and culturally responsive model that focuses on recovery, shared decision-making and psychosocial care. With the appropriate governmental and agency-level provision of resources and modifications to some of the program components, particularly regarding the shared decision-making framework, peer specialist, family engagement, and the training supervision model, OTCH could be a transformative program for a more comprehensive, evidence-based care for individuals with FEP in Chile.

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BACKGROUND: Pulmonary arterial hypertension (PAH) is characterized by elevated pulmonary arterial pressures and is managed by vasodilator therapies. Current guidelines encourage PAH management in specialty care centers (SCCs), but evidence is sparse regarding improvement in clinical outcomes and correlation to vasodilator use with referral. RESEARCH QUESTION: Is PAH management at SCCs associated with improved clinical outcomes? STUDY DESIGNAND METHODS: A single-center, retrospective study was performed at the University of Pittsburgh Medical Center (UPMC; overseeing 40 hospitals). Patients with PAH were identified between 2008 and 2018 and classified into an SCC or non-SCC cohort. Cox proportional hazard modeling was done to compare for all-cause mortality, as was negative binomial regression modeling for hospitalizations. Vasodilator therapy was included to adjust outcomes. RESULTS: Of 580 patients with PAH at UPMC, 455 (78%) were treated at the SCC, comprising a younger (58.8 vs 64.8 years; P < .001) and more often female (68.4% vs 51.2%; P < .001) population with more comorbidities without differences in race or income. SCC patients demonstrated improved survival (hazard ratio, 0.68; P = .012) and fewer hospitalizations (incidence ratio, 0.54; P < .001), and provided more frequent disease monitoring. Early patient referral to SCC (< 6 months from time of diagnosis) was associated with improved outcomes compared with non-SCC patients. SCC patients were more frequently prescribed vasodilators (P < .001) and carried more diagnostic PAH coding (P < .001). Vasodilators were associated with improved outcomes irrespective of location but without statistical significance when comparing between locations (P > .05). INTERPRETATION: The UPMC SCC demonstrated improved outcomes in mortality and hospitalizations. The SCC benefit was multifactorial, with more frequent vasodilator therapy and disease monitoring. These findings provide robust evidence for early and regular referral of patients with PAH to SCCs.

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OBJECTIVES: To test a collaborative care model for interfacing sleep specialists with primary care providers to enhance patients' sleep disorders management. METHODS: This study used a randomized, parallel group, clinical intervention trial design. A total of 137 adult (29 women) VA outpatients with sleep complaints were enrolled and randomly assigned to (1) an intervention (INT) consisting of a one-time consultation with a sleep specialist who provided diagnostic feedback and treatment recommendations to the patient and the patient's primary care provider; or (2) a control condition consisting of their usual primary care (UPC). Provider-focused outcomes included rates of adherence to recommended diagnostic procedures and sleep-focused interventions. Patient-focused outcomes included measures taken from sleep diaries and actigraphy; Pittsburgh Sleep Quality Index (PSQI) scores; and self-report measures of sleepiness, fatigue, mood, quality of life, and satisfaction with health care. RESULTS: The proportions of provider-initiated sleep-focused interventions were significantly higher in the INT group than in the UPC group for polysomnography referrals (49% versus 6%; P < 0.001) and mental health clinic referrals (19% versus 6%; P = 0.02). At the 10-mo follow up, INT recipients showed greater estimated mean reductions in diary total wake time (-17.0 min; 95% confidence interval [CI]: -30.9, -3.1; P = 0.02) and greater increases in sleep efficiency (+3.7%; 95% CI: 0.8, 6.5; P = 0.01) than did UPC participants. A greater proportion of the INT group showed ≥ 1 standard deviation decline on the PSQI from baseline to the 10-mo follow-up (41% versus 21%; P = 0.02). Moreover, 69% of the INT group had normal (≤ 10) Epworth Sleepiness Scale scores at the 10-mo follow-up, whereas only 50% of the UPC group fell below this clinical cutoff (P = 0.03). CONCLUSIONS: A one-time sleep consultation significantly increased healthcare providers' attention to sleep problems and resulted in benefits to patients' sleep/wake symptoms. CLINICAL TRIALS REGISTRATION: This study is registered with clinicaltrials.gov with identifier # NCT00390572.

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