ABSTRACT
Introduction: Federal agencies announced in March 2020 regulatory changes for opioid treatment programs (OTPs) to ensure patient and staff safety - extended methadone take-home dosing and increased use of telehealth counseling. Qualitative interviews explored OTP patient and staff perceptions on how the COVID 19 pandemic and these regulatory changes impacted addiction treatment engagement and recovery support. Method(s): Semi-structured, one-to-one telephone interviews were completed between August 2020 and January 2021 with 46 patients with varying amounts of take-home doses and 6 staff from 3 rural OTPs in Oregon. Interviews were audio-recorded, and transcribed verbatim. Transcriptions were coded at the semantic level, with codes generated both deductively and inductively. Directed content analysis extracted themes in an iterative process. Result(s): Staff worried more than patients about return to opioid use due to COVID-19 related stressors. Staff were concerned about reduced contact and interaction with patients they previously had with group and individual counseling, despite telemedicine availability. Patients voiced anxiety about contracting COVID-19 or transmitting the virus to their families and communities while engaging in methadone treatment. A few patients with extended methadone take-home regimens requested to return to daily clinic dosing for enhanced staff/clinic support stating they were too new in recovery. Some patients struggled with their mental health, noting social isolation, and missing the usual recovery supports of in-person counseling at the OTP. Others, however, stated it helped to keep to yourself. Conclusion(s): OTPs perform a vital service of providing patients mental health services during public health emergencies. During COVID, patients and staff reflected on adjusting to new regulatory procedures and policies, despite increased anxiety and changing support needs. There was a range of preferences, signaling that a single approach may work for most but can be detrimental to some. To the extent it is feasible, OTPs should offer more individualized treatment plans.
ABSTRACT
Introduction: The COVID-19 pandemic has required rapid reconfiguration of healthcare services from in-person to telemedicine. Positive Airway Pressure (PAP) is the gold-standard treatment for sleep apnea, but success requires substantial clinical support, which has traditionally been provided in-person. In this quality analysis, we examined the impact of PAP initiation (PAPI) via telemedicine on adherence and subsequent health care utilization, compared to the conventional, in-person model. Methods: Patients who completed PAPI and initial adherence period between April-August 2020 were included. During this window, telemedicine visits were encouraged, but not required. Adequate adherence status was considered met if 21/30 consecutive days with use >4h was achieved by day 90 therapy. Health care utilization was represented by the number of follow-up visits, stratified by provider type (Physician, Physician Assistant (PA), or PAP Technologist). Results: 839 patients (54% telemedicine, 46% in-person), 38.0% female, aged 54.2±0.5 years, BMI 32.4±0.3 (±SEM) were included. Adherence was similarly achieved following both initiation methods: 78.8% (telemedicine) and 76.4% (in-person) (p>0.4). Clinical follow-up was lower after in-person PAPI compared to telemedicine, regardless of adherence status (p<0.05). Non-adherent patients also had less clinical follow-up than adherent patients after both initiation methods (p<0.0001), though this differed by provider type. Non-adherent patients in both initiation methods were less likely to follow-up with a PA or PAP Technologist (p<0.01), though follow-up rate with Physician providers was similar (p>0.1). Clinical follow-up with PAP Technologist was increased after telemedicine compared to in-person PAPI (p<0.01). Conclusion: Implementation of a telemedicine PAP initiation protocol during the COVID-19 pandemic resulted in similar rates of adherence compared to the conventional in-person method, which suggests that telemedicine is an appropriate alternative to in-person PAPI. However, clinical follow-up was lower after in-person PAPI compared to telemedicine regardless of adherence status. Further, non-adherent patients had less follow-up with PAs and PAP Technologists, but similar follow-up with Physicians. This may indicate that provider type plays a role in supporting patients through the adherence process and should be considered. Further research is needed to understand the relationship between care teams, adherence, and healthcare utilization in the age of telemedicine.