The Impact of Completing X-Waiver Training and Clinical Addiction Exposure on Internal Medicine Residents Treating Patients With Opioid Use Disorder.

BACKGROUND: Treating opioid use disorder (OUD) with buprenorphine or methadone significantly reduces overdose and all-cause mortality. Prior studies demonstrate that clinicians and residents reported a lack of preparedness to diagnose or treat OUD. Little is known about how clinical exposure or buprenorphine X-waiver training impacts OUD care delivery by resident physicians. OBJECTIVE: Distinguish the effects of X-waiver training and clinical exposure with OUD on resident's knowledge, attitudes, feelings of preparedness, and practices related to OUD treatment provision. METHODS: From August 2021 to April 2022, we distributed a cross-sectional survey to internal medicine residents at a large academic training program. We analyzed associations between self-reported clinical exposure and X-waiver training across 4 domains: knowledge about best practices for OUD treatment, attitudes about patients with OUD, preparedness to treat OUD, and clinical experience with OUD. RESULTS: Of the 188 residents surveyed, 91 responded (48%). A majority of respondents had not completed X-waiver training (60%, n = 55) while many had provided clinical care to patients with OUD (65%, n = 59). Most residents had favorable attitudes about OUD treatment (97%). Both residents with clinical exposure to treating OUD and X-waiver training, and residents with clinical exposure without X-waiver training, felt more prepared to treat OUD (P < .0008) compared to residents with neither clinical exposure or X-waiver training or only X-waiver training. CONCLUSIONS: Residents with clinical exposure to treating OUD are more prepared to treat patients with OUD than those without clinical exposure. Greater efforts to incorporate clinical exposure to the treatment of OUD and education in internal medicine residency programs is imperative to address the opioid epidemic.

Impact of Clinical Demands on the Educational Mission in Hospital Medicine at 17 Academic Medical Centers : A Qualitative Analysis.

BACKGROUND: Clinical growth is outpacing the growth of traditional educational opportunities at academic medical centers (AMCs). OBJECTIVE: To understand the impact of clinical growth on the educational mission for academic hospitalists. DESIGN: Qualitative study using semistructured interviews that were analyzed using a mixed inductive and deductive method at the semantic level. SETTING: Large AMCs across the United States that experienced clinical growth in the past 5 years. PARTICIPANTS: Division heads, section heads, and other hospital medicine (HM) leaders who oversaw and guided academic and clinical efforts of HM programs. MEASUREMENTS: Themes and subthemes. RESULTS: From September 2021 to January 2022, HM leaders from 17 AMCs participated in the interviews, and 3 key themes emerged. First, AMCs' disproportionate clinical growth highlighted the tension between clinical and educational missions. This included a mismatch in supply and demand for traditional teaching time, competing priorities, and clinical growth being seen as both an opportunity and a threat. Second, amid the shifting landscape of high clinical demands and evolving educational opportunities, hospitalists still strongly prefer traditional teaching. To address this mismatch, HM groups have had to alter recruitment strategies and create innovative solutions to help build academic careers. Third, participants noted a need to reimagine the role and identity of an academic hospitalist, emphasizing tailored career pathways and educational roles spanning well beyond traditional house staff teaching teams. LIMITATION: The study focused on large AMCs. CONCLUSION: Although HM groups have implemented many creative strategies to address clinical growth and keep education front and center, challenges remain, particularly heavy clinical workloads and a continued dilution of traditional teaching opportunities. PRIMARY FUNDING SOURCE: Society of Hospital Medicine Student Scholar Grant.

Experiences of stigma in hospitals with addiction consultation services: A qualitative analysis of patients' and hospital-based providers' perspectives.

BACKGROUND: Addiction consultation services (ACS) provide evidence-based treatment to hospitalized patients with substance use disorders (SUD). Expansion of hospital-based addiction care may help to counteract the stigma that patients with SUD experience within the health care system. Stigma is among the most impactful barriers to seeking care and adhering to medical advice among people with SUD. We aimed to understand how the presence of an ACS affected patients' and hospital-based providers' experiences with stigma in the hospital setting. METHODS: We conducted a qualitative study utilizing focus groups and key informant interviews with hospital-based providers (hospitalists and hospital-based nurses, social workers, pharmacists). We also conducted key informant interviews with patients who received care from an ACS during their hospitalization. An interprofessional team coded and analyzed transcripts using a thematic analysis approach to identify emergent themes. RESULTS: Sixty-two hospital-based providers participated in six focus groups or eight interviews. Twenty patients participated in interviews. Four themes emerged relating to the experiences of stigma reported by hospital-based providers and hospitalized patients with SUD: (1) past experiences in the health care system propagate a cycle of stigmatization between hospital-based providers and patients; (2) documentation in medical charts unintentionally or intentionally perpetuates enacted stigma among hospital-based providers resulting in anticipated stigma among patients; (3) the presence of an ACS reduces enacted stigma among hospital-based providers through expanding the use of evidenced-based SUD treatment and reframing the SUD narrative; (4) ACS team members combat the effects of internalized stigma by promoting feelings of self-worth, self-efficacy, and mutual respect among patients with SUD. CONCLUSIONS: An ACS can facilitate destigmatization of hospitalized patients with SUD by incorporating evidence-based SUD treatment into routine hospital care, by providing and modeling compassionate care, and by reframing addiction as a chronic condition to be treated alongside other medical conditions. Future reductions of stigma in hospital settings may result from promoting greater use of evidence-based treatment for SUD and expanded education for health care providers on the use of non-stigmatizing language and medical terminology when documenting SUD in the medical chart.

Opioid Use Disorder Treatment Initiation and Continuation: a Qualitative Study of Patients Who Received Addiction Consultation and Hospital-Based Providers.

BACKGROUND: Hospitalizations related to opioid use disorder (OUD) are rising. Addiction consultation services (ACS) increasingly provide OUD treatment to hospitalized patients, but barriers to initiating and continuing medications for OUD remain. We examined facilitators and barriers to hospital-based OUD treatment initiation and continuation from the perspective of patients and healthcare workers in the context of an ACS. METHODS: In this qualitative study, we sought input using key informant interviews and focus groups from patients who received care from an ACS during their hospitalization and from hospitalists, pharmacists, social workers, and nurses who work in the hospital setting. A multidisciplinary team coded and analyzed transcripts using a directed content analysis. FINDINGS: We conducted 20 key informant interviews with patients, nine of whom were interviewed following hospital discharge and 12 of whom were interviewed during a rehospitalization. We completed six focus groups and eight key informant interviews with hospitalists and hospital-based medical staff (n = 62). Emergent themes related to hospital-based OUD treatment included the following: the benefit of an ACS to facilitate OUD treatment engagement; expanded use of methadone or buprenorphine to treat opioid withdrawal; the triad of hospitalization, self-efficacy, and easily accessible, patient-centered treatment motivates change in opioid use; adequate pain control and stabilization of mental health conditions among patients with OUD contributed to opioid agonist therapy (OAT) continuation; and stable housing and social support are prerequisites for OAT uptake and continuation. CONCLUSION: Modifiable factors which facilitate hospital-based OUD treatment initiation and continuation include availability of in-hospital addiction expertise to offer easily accessible, patient-centered treatment and the use of methadone or buprenorphine to manage opioid withdrawal. Further research and public policy efforts are urgently needed to address reported barriers to hospital-based OUD treatment initiation and continuation which include unstable housing, poorly controlled chronic medical and mental illness, and lack of social support.

Experiences with an addiction consultation service on care provided to hospitalized patients with opioid use disorder: a qualitative study of hospitalists, nurses, pharmacists, and social workers.

Background: In response to the opioid epidemic, addiction consultation services (ACS) increasingly provide dedicated hospital-based addiction treatment to patients with substance use disorder. We assessed hospitalist and medical staff perceptions of how the presence of 2 hospitals' ACS impacted care for hospitalized patients with opioid use disorder (OUD). We inquired about ongoing challenges in caring for this patient population.Methods: We conducted a qualitative study of hospital-based providers utilizing focus groups and key informant interviews for data collection. Transcripts were analyzed using a mixed inductive-deductive approach. Emergent themes were identified through an iterative, multidisciplinary team-based process using a directed content analysis approach.Results: Hospitalists (n = 20), nurses (n = 13), social workers (n = 11), and pharmacists (n = 18) from a university hospital and a safety-net hospital in Colorado participated in focus groups or key informant interviews. In response to the availability of an ACS, hospitalists described increased confidence using methadone and buprenorphine to treat opioid withdrawal, which they perceived as contributing to improved patient outcomes and greater job satisfaction. Participants expressed concern about inconsistent care provided to patients with OUD that varied by the admitting team's specialty and the physician's background and training. Nurses and hospitalists reported frustrations with achieving adequate pain control among patients with OUD. Last, pharmacists reported practice variations when physicians dosed buprenorphine for acute pain among patients with OUD. A lack of standardized dosing led to concerns of inadequate analgesia or return to opioid use following hospital discharge.Conclusions: An ACS reportedly supports hospitalists and medical staff to best care for hospitalized patients with OUD. Notably, care provided to patients with OUD may not be uniform depending on various physician-level factors. Future work to address the concerns reported by study participants may include education for OUD treatment, early involvement of the ACS, and incorporation of buprenorphine prescribing algorithms to standardize care.

A Cross-Sectional Survey of Internal Medicine Residents' Knowledge, Attitudes, and Current Practices Regarding Patient Transitions to Post-Acute Care.

OBJECTIVES: Prior studies have found suboptimal knowledge about post-acute care (PAC) among inpatient providers and poor communication at discharge that can lead to unsafe discharge transitions, but little is known about residents and the PAC transition. The aim of this study is to assess internal medicine residents' knowledge, attitudes, and current practice regarding patient transitions to PAC. DESIGN: A multisite, cross-sectional 36-question survey. SETTING AND PARTICIPANTS: Internal Medicine and Medicine-Pediatrics residents at 3 university-based Internal Medicine training programs in the United States. METHODS: Survey delivered electronically to residents in 2018 and 2019. Survey responses were described by collapsing 4-point Likert responses into dichotomous variables, and thematic content analysis was used to evaluate free text responses. RESULTS: Of 482 residents surveyed, 236 responded (49%). Despite high reported confidence in their ability to transition patients to PAC, only 31% of residents knew how often patients received skilled therapies at skilled nursing facilities (SNFs) and 23% knew how frequently nursing services are provided. The majority of residents (79%) identified the discharge summary as the main way they communicated care instructions to the SNF, but only 55% reported always completing it prior to discharge. Upper-level residents were more likely to know how much therapy patients received at a SNF, but resident knowledge about PAC did not vary by residency year in other domains. Residents who experienced a clinical rotation at a SNF had higher levels of knowledge compared to residents who did not. CONCLUSIONS: This national survey of internal medicine residents identified common knowledge gaps regarding PAC. These knowledge gaps did not improve throughout residency without deliberate exposure to PAC environments. This suggests a need for dedicated curriculum development as discharges to PAC continue to rise exponentially.

Caregiver Experiences of Care Coordination for Recently Discharged Patients: A Qualitative Metasynthesis.

Caregivers of patients often provide key support for patients after hospitalization. This qualitative metasynthesis describes caregiver perspectives about care coordination for patients discharged from the hospital. A literature search of Ovid Medline and CINAHL completed on May 23, 2018, identified 1,546 studies. Twelve articles were included in the final metasynthesis. Caregiver perspectives about care coordination were compiled into overall themes. A subanalysis of studies in which patients were discharged with home health services was completed. Five main themes emerged related to caregiver perspectives on care coordination after hospitalization: (a) Suboptimal access to clinicians after discharge, (b) Feeling disregarded by clinicians, (c) Need for information and training at discharge, (d) Overwhelming responsibilities to manage appointments and medications, and (e) Need for emotional support.Findings from this metasynthesis suggest the need for clinicians to engage with caregivers to provide support, training, and communication after hospital discharge.

Pluripotency transcription factor Oct4 mediates stepwise nucleosome demethylation and depletion.

The mechanisms whereby the crucial pluripotency transcription factor Oct4 regulates target gene expression are incompletely understood. Using an assay system based on partially differentiated embryonic stem cells, we show that Oct4 opposes the accumulation of local H3K9me2 and subsequent Dnmt3a-mediated DNA methylation. Upon binding DNA, Oct4 recruits the histone lysine demethylase Jmjd1c. Chromatin immunoprecipitation (ChIP) time course experiments identify a stepwise Oct4 mechanism involving Jmjd1c recruitment and H3K9me2 demethylation, transient FACT (facilitates chromatin transactions) complex recruitment, and nucleosome depletion. Genome-wide and targeted ChIP confirms binding of newly synthesized Oct4, together with Jmjd1c and FACT, to the Pou5f1 enhancer and a small number of other Oct4 targets, including the Nanog promoter. Histone demethylation is required for both FACT recruitment and H3 depletion. Jmjd1c is required to induce endogenous Oct4 expression and fully reprogram fibroblasts to pluripotency, indicating that the assay system identifies functional Oct4 cofactors. These findings indicate that Oct4 sequentially recruits activities that catalyze histone demethylation and depletion.

Practice effects: a unique cognitive variable.

Practice effects are improvements in cognitive test performance due to repeated evaluation with the same or similar test materials. Prior studies have reported that these improvements can vary with age, education/intellect, and disease status. However, additional information is needed about variables that influence practice effects. The current study prospectively quantified short-term practice effects in 268 community-dwelling older adults and compared these practice effects to demographic variables, global cognition, premorbid intellect, depression, and individual cognitive domains. Overall, practice effects were not significantly related to most demographic and clinical characteristics or individual cognitive domains, which was contrary to our hypotheses. However, since practice effects appear to be uninfluenced by many variables that typically affect cognitive scores, they may be a unique and valuable tool that could be applied in a number of diverse patient groups.

High-throughput biochemical analysis of in vivo location data reveals novel distinct classes of POU5F1(Oct4)/DNA complexes.

The transcription factor POU5F1 is a key regulator of embryonic stem (ES) cell pluripotency and a known oncoprotein. We have developed a novel high-throughput binding assay called MEGAshift (microarray evaluation of genomic aptamers by shift) that we use to pinpoint the exact location, affinity, and stoichiometry of the DNA-protein complexes identified by chromatin immunoprecipitation studies. We consider all genomic regions identified as POU5F1-ChIP-enriched in both human and mouse. Compared with regions that are ChIP-enriched in a single species, we find these regions more likely to be near actively transcribed genes in ES cells. We resynthesize these genomic regions as a pool of tiled 35-mers. This oligonucleotide pool is then assayed for binding to recombinant POU5F1 by gel shift. The degree of binding for each oligonucleotide is accurately measured on a custom oligonucleotide microarray. We explore the relationship between experimentally determined and computationally predicted binding strengths, find many novel functional combinations of POU5F1 half sites, and demonstrate efficient motif discovery by incorporating binding information into a motif finding algorithm. In addition to further refining location studies for transcription factors, this method holds promise for the high-throughput screening of promoters, SNP regions, and epigenetic modifications for factor binding.