The Association Between Sensemaking During Physician Team Rounds and Hospitalized Patients' Outcomes.

BACKGROUND: Sensemaking is the social act of assigning meaning to ambiguous events. It is recognized as a means to achieve high reliability. We sought to assess sensemaking in daily patient care through examining how inpatient teams round and discuss patients. OBJECTIVE: Our purpose was to assess the association between inpatient physician team sensemaking and hospitalized patients' outcomes, including length of stay (LOS), unnecessary length of stay (ULOS), and complication rates. DESIGN: Eleven inpatient medicine teams' daily rounds were observed for 2 to 4 weeks. Rounds were audiotaped, and field notes taken. Four patient discussions per team were assessed using a standardized Situation, Task, Intent, Concern, Calibrate (STICC) framework. PARTICIPANTS: Inpatient physician teams at the teaching hospitals affiliated with the University of Texas Health Science Center at San Antonio participated in the study. Outcomes of patients admitted to the teams were included. MAIN MEASURES: Sensemaking was assessed based on the order in which patients were seen, purposeful rounding, patient-driven rounding, and individual patient discussions. We assigned teams a score based on the number of STICC elements used in the four patient discussions sampled. The association between sensemaking and outcomes was assessed using Kruskal-Wallis sum rank and Dunn's tests. KEY RESULTS: Teams rounded in several different ways. Five teams rounded purposefully, and four based rounds on patient-driven needs. Purposeful and patient-driven rounds were significantly associated with lower complication rates. Varying the order in which patients were seen and purposefully rounding were significantly associated with lower LOS, and purposeful and patient-driven rounds associated with lower ULOS. Use of a greater number of STICC elements was associated with significantly lower LOS (4.6 vs. 5.7, p = 0.01), ULOS (0.3 vs. 0.6, p = 0.02), and complications (0.2 vs. 0.5, p = 0.0001). CONCLUSIONS: Improving sensemaking may be a strategy for improving patient outcomes, fostering a shared understanding of a patient's clinical trajectory, and enabling high reliability.

Relationships within inpatient physician housestaff teams and their association with hospitalized patient outcomes.

IMPORTANCE: Improving inpatient care delivery has historically focused on improving individual components of the system. Applying the complexity science framework to clinical systems highlights the important role of relationships among providers in influencing system function and clinical outcomes. OBJECTIVE: To understand whether inpatient medical physician teams can be differentiated based on the relationships among team members, and whether these relationships are associated with patient outcomes, including length of stay (LOS), unnecessary length of stay (ULOS), and complication rates. DESIGN: Eleven inpatient medicine teams were observed daily during attending rounds for 2- to 4-week periods from September 2008 through June 2011. Detailed field notes were taken regarding patient care activities, team behaviors, and patient characteristics and outcomes. Behaviors were categorized using the Lanham relationship framework, giving each team a relationship score. We used factor analysis to assess the pattern of relationship characteristics and assessed the association between relationship characteristics and patient outcomes. SETTING: Observations occurred at the Audie L. Murphy Veterans Affairs Hospital and University Hospital in San Antonio, Texas. PARTICIPANTS: Physicians were chosen based on rotation schedules, experience, and time of year. Patients were included based on their admission to the inpatient medicine teams that were being observed. MAIN MEASURES: Relationship scores were based on the presence or absence of 7 relationship characteristics. LOS, ULOS, and complication rates were assessed based on team discussions and chart review. The association between relationships and outcomes was assessed using the Kruskal-Wallis rank sum test. RESULTS: We observed 11 teams over 352.9 hours, observing 1941 discussions of 576 individual patients. Teams exhibited a range of 0 to 7 relationship characteristics. Relationship scores were significantly associated with complication rates, and presence of trust and mindfulness among teams was significantly associated with ULOS and complication rates. CONCLUSIONS: Our findings are an important step in understanding the impact of relationships on the outcomes of hospitalized medical patients. This understanding could expand the scope of interventions to improve hospital care to include not only process improvement but also relationships among providers.

Redefining retention: recovery from the patient's perspective.

This study examines the process of discharge and treatment reentry for six participants who entered treatment voluntarily but were administratively discharged from methadone treatment programs. The participants completed semistructured interviews at treatment entry and at four, eight and 12 months post-treatment entry. Grounded theory methodology was used to examine the phenomenon of treatment reentry from the perspective of the patients, who often viewed their recovery as an accumulation of positive changes. Differences in terms of the patients' goals and motivations for seeking treatment from those of the treatment programs, combined with difficulties encountered during the treatment process eventually led to discharge. However, these patients were then able to navigate their way through the treatment system in different ways in order to remain in treatment. The authors conclude that failure to abide by treatment clinic rules do not necessary constitute "treatment failure" from the perspective of patients, who often wish to remain in treatment even if it is not progressing optimally from the program's perspective. As a result, the recovery process can be more fragmented and is often characterized by a series of cyclical treatment episodes rather than continuous time in treatment, thereby impeding their progress towards recovery.

Why don't out-of-treatment individuals enter methadone treatment programmes?

BACKGROUND: Despite the proven effectiveness of methadone treatment, the majority of heroin-dependent individuals are out-of-treatment. METHODS: Twenty-six opioid-dependent adults who met the criteria for methadone maintenance who were neither seeking methadone treatment at the time of study enrollment, nor had participated in such treatment during the past 12 months, were recruited from the streets of Baltimore, Maryland through targeted sampling. Ethnographic interviews were conducted to ascertain participants' attitudes toward methadone treatment and their reasons for not seeking treatment. RESULTS: Barriers to treatment entry included: waiting lists, lack of money or health insurance, and requirements to possess a photo identification card. For some participants, beliefs about methadone such as real or rumored side effects, fear of withdrawal from methadone during an incarceration, or disinterest in adhering to the structure of treatment programmes kept them from applying. In addition, other participants were not willing to commit to indefinite "maintenance" but would have accepted shorter time-limited methadone treatment. CONCLUSION: Barriers to treatment entry could be overcome by an infusion of public financial support to expand treatment access, which would reduce or eliminate waiting lists, waive treatment-related fees, and/or provide health insurance coverage for treatment. Treatment programmes could overcome some of the barriers by waiving their photo I.D. requirements, permitting time-limited treatment with the option to extend such treatment upon request, and working with corrections agencies to ensure continued methadone treatment upon incarceration.

Premature discharge from methadone treatment: patient perspectives.

Longer retention in drug abuse treatment is associated with better patient outcomes, and research indicates the first 12 months of methadone treatment are critical to patient success. Nevertheless, large-scale multisite longitudinal studies over the past three decades indicate that the majority of patients drop out during the first year of methadone treatment. Through an examination of 42 qualitative interviews with patients prematurely discharged from six methadone treatment programs in Baltimore, this study highlights factors patients describe as contributing to their reasons for being discharged within the first 12 months of the treatment. The two most consistent themes are program-related factors and incarceration. The former factors are richly described through patients' words and underscore the ways in which patients' perceptions of control exerted by the program and by the medication and misunderstandings of program structure can lead to premature discharge. Patients' reasons for discharge were compared to counselors' reasons as indicated in discharge summary forms. An analysis of the patterns of agreement and disagreement are presented. Patient-centered program and policy implications are discussed.

Uses of diverted methadone and buprenorphine by opioid-addicted individuals in Baltimore, Maryland.

This study examined the uses of diverted methadone and buprenorphine among opiate-addicted individuals recruited from new admissions to methadone programs and from out-of-treatment individuals recruited from the streets. Self-report data regarding diversion were obtained from surveys and semi-structured qualitative interviews. Approximately 16% (n = 84) of the total sample (N = 515) reported using diverted (street) methadone two-three times per week for six months or more, and for an average of 7.8 days (SD = 10.3) within the past month. The group reporting lifetime use of diverted methadone as compared to the group that did not report such use was less likely to use heroin and cocaine in the 30 days prior to admission (ps <.01) and had lower ASI Drug Composite scores (p <.05). Participants in our qualitative sub-sample (n = 22) indicated that street methadone was more widely used than street buprenorphine and that both drugs were largely used as self-medication for detoxification and withdrawal symptoms. Participants reported using low dosages and no injection of either medication was reported.

Incarceration and opioid withdrawal: the experiences of methadone patients and out-of-treatment heroin users.

Both heroin-addicted individuals and methadone maintenance patients are likely to face untreated opioid withdrawal while incarcerated. Limited research exists concerning the withdrawal experiences of addicted inmates and their impact on individuals' attitudes and plans concerning drug abuse treatment. In the present study, 53 opioid dependent adults (32 in methadone treatment and 21 out of treatment) were interviewed in an ethnographic investigation of withdrawal experiences during incarceration. When treatment for opioid withdrawal was unavailable, detoxification experiences were usually described as negative and were often associated with a variety of unhealthy behaviors designed to relieve withdrawal symptoms. Negative methadone withdrawal experiences also negatively influenced participants' receptivity to seeking methadone treatment upon release. A minority of participants took a positive view of their withdrawal experience and saw it as an opportunity to detox from heroin or discontinue methadone. Findings support the importance of providing appropriate opioid detoxification and/or maintenance therapy to opioid-dependent inmates.

Gender Differences Among In- and Out-of-Treatment Opioid-Addicted Individuals.

OBJECTIVE: Gender differences were explored among 355 in- and out-of-treatment opioid-addicted adults in Baltimore. METHODS: Addiction Severity Index and other variables were compared among: 1) in-treatment women vs. out-of-treatment women; 2) out-of-treatment: women vs. men; and, 3) in-treatment: women vs. men. RESULTS: Analysis indicated that in-treatment and out-of-treatment women worked less and used more cocaine than their male counterparts (ps < .01). Moreover, out-of-treatment women used heroin and cocaine more often, spent more money on drugs, earned more illegal income, and had fewer treatments than in-treatment women (ps < or = .01). CONCLUSIONS: Findings indicate greater severity of drug and employment problems of opioid-addicted women and underline the need for gender-specific drug-treatment services.

Attitudes toward buprenorphine and methadone among opioid-dependent individuals.

Attitudes and beliefs about drug abuse treatment have long been known to shape response to that treatment. Two major pharmacological alternatives are available for opioid dependence: methadone, which has been available for the past 40 years, and buprenorphine, a recently introduced medication. This mixed-methods study examined the attitudes of opioid-dependent individuals toward methadone and buprenorphine. A total of 195 participants (n = 140 who were enrolling in one of six Baltimore area methadone programs and n = 55 who were out-of-treatment) were administered the Attitudes toward Methadone and toward Buprenorphine Scales, and a subset (n = 46) received an ethnographic interview. The in-treatment group had significantly more positive attitudes toward methadone than did the out-of-treatment group (p < .001), while they did not differ in their attitudes toward buprenorphine. Both groups had significantly more positive attitudes toward buprenorphine than methadone. Addressing these attitudes may increase treatment entry and retention.

In-treatment vs. out-of-treatment opioid dependent adults: drug use and criminal history.

This study compared the characteristics of opioid-addicted adults seeking (n = 169) and not seeking (n = 74) methadone treatment in Baltimore, Maryland. Participants entering treatment were recruited from six methadone treatment programs, while out-of-treatment participants were recruited from the streets using targeted sampling methods. Measures included the Addiction Severity Index, a Supplemental Questionnaire, and urine drug test. Data were analyzed using ANOVA, chi(2), and regression, holding key background variables constant. Despite the lack of differences between the samples in demographic characteristics, the out-of-treatment sample reported significantly more days of heroin, cocaine, and alcohol use and spent significantly more money on drugs and earned more illegal income at baseline.

Getting clean and harm reduction: adversarial or complementary issues for injection drug users.

Many contemporary HIV prevention interventions targeting injection drug users (IDUs) have been implemented using Harm Reduction as a theoretical framework. Among drug-using individuals, however, the abstinence-based "getting clean" models espoused by Narcotics Anonymous and other widely adopted approaches to drug treatment are often more readily accepted. This paper describes an ethnographic examination of the ideological dichotomy between Harm Reduction and abstinence-based "getting clean" treatment model which emerged during the piloting phase of an HIV prevention intervention in Baltimore City, Maryland, USA. This paper describes how the conflict was identified and what changes were made to the intervention to help resolve the participants' dichotomous thinking concerning their substance abuse issues.

Getting clean and harm reduction: adversarial or complementary issues for injection drug users

Muitas intervencões para prevenir a infeccão pelo HIV entre usuários de drogas injetáveis adotam a técnica de reducão de danos como referencial teórico. Entretanto, os próprios usuários tendem a preferir modelos baseados na abstinência, defendidos pelos Narcóticos Anônimos, além de outras abordagens adotadas amplamente para o tratamento da dependência química. O artigo descreve uma avaliacão etnográfica da dicotomia ideológica entre reducão de danos e o modelo terapêutico baseado na abstinência (getting clean) durante a fase piloto de uma intervencão para a prevencão de HIV na Cidade de Baltimore, Maryland, Estados Unidos. O artigo descreve como o conflito foi identificado e que mudancas foram introduzidas na intervencão para ajudar a resolver as idéias dicotômicas dos participantes em relacão às questões de dependência química.

Ecstasy: commodity or disease?

This article evaluates past work on heroin and crack cocaine epidemics by comparing it with the increase in Ecstasy use in the late 1990s. First of all, the authors make the case that there was, in fact, a dramatic increase in Ecstasy use in the late 1990s. Following that is a review of the rise and fall of several different Ecstasy scenes beginning in the 1960s. The most recent rise, in the late 1990s, requires a broadening of the theory of epidemics to include longer historical waves of change, so we do that by reviewing work on post World War II trends in social disconnection and consumerism. We then shift to a marketing rather than a public health framework and look at the nature of the Ecstasy "product," both its good and bad characteristics. Finally, we describe the narrative mechanism, developed in our earlier work, that plausibly explains why use rose when it did, given the needs of the market. The article concludes by discussing the changes this case motivates for our theory, particularly in light of globalized and normalized drug use that at the moment appears to be the current context for illicit drug use.

Know when to hold 'em, know when to fold 'em: qualitative thinking outside the university.

Qualitative researchers often face a dilemma. They are asked to apply their knowledge to problems without adequate time or support to conduct projects that meet traditional academic standards of research design and methodology. Should qualitative researchers pitch in and get involved or keep their distance? What can they hope to accomplish, if anything? How do they know whether a particular job can be done? Traditional research training provides few guidelines to answer such questions. In this article, the author explores one way to think about what such guidelines might look like.

Toward a qualitative epidemiology.

This article is based on an invited keynote lecture to the Qualitative Health Research meetings in Banff, Alberta, in April 2002 and so is written in an informal style. The author begins with problems in traditional epidemiology, with its focus on the case record and the epidemiological triad of host, agent, and environment. The idea of a person-in-context "movie" is offered as an alternative kind of case record, and broader issues of identity and context are added to enrich the explanations of those records. In the original presentation, an agent-based model in the style of complexity theory was demonstrated. That model is beyond the scope of this article and is now under review by a complexity journal; a draft manuscript is available on request.

A heroin epidemic at the intersection of histories: the 1960s epidemic among African Americans in Baltimore.

In the drug field the fundamental epidemiological question-why illicit drug use, here, now, among these people-has still not been adequately answered. Drawing on the work of colleagues in medical anthropology, we attempt to move closer to an answer by developing a "trend theory." In this article we analyze a single case: the increase in heroin use and addiction among African Americans in the City of Baltimore in the 1960s. We found that the two most important historical processes behind the epidemic were (1) a changing distribution/supply system and (2) the mix of hope and despair that was part of the early civil rights movement.

A tale of two policies: the French connection, methadone, and heroin epidemics.

The law enforcement and treatment policies of the Nixon administration are often credited with ending the epidemic of heroin addiction that rose in America's cities in the 1960s. In this article it is argued that although the interventions did in fact cause a major change in heroin distribution and use, the epidemic did not end in any simple way. The decline in heroin and increase in methadone that resulted from the Nixon policies lead to a shift for many addicts in both clinical and street settings from one narcotic to another. The temporary shortage of heroin that resulted from law enforcement was quickly compensated for with methadone, as well as with new distribution systems from Southeast Asia and Mexico. In the end, the interventions caused a change in an enduring "heroin system," a change that left that system in a stronger form in terms of supply and in a situation of continuing growth in terms of the number of addicts.