Patient Engagement in and Adaptations to Delivery of Outpatient Care for Opioid Use Disorder During the COVID-19 Pandemic.

OBJECTIVE: The authors investigated adaptations to outpatient care delivery and changes in treatment demand and engagement among patients receiving medications for opioid use disorder (MOUD) in the months after the declaration of the COVID-19 public health emergency in 2020. METHODS: Data were collected through an online survey (June-November 2020) of outpatient MOUD prescribers. The survey obtained information on outpatient practices' adaptations to MOUD treatment and urine drug screening (UDS) and elicited provider views on the effects of the COVID-19 pandemic on patient demand for, and engagement in, treatment. Multivariable regression analyses were used to examine associations among practice characteristics, patient engagement, and service adaptations. RESULTS: Of 516 respondents, 74% reported adaptations to MOUD delivery during the pandemic. Most respondents implemented virtual visits for initial (67%) and follow-up (77%) contacts. Prescribers of buprenorphine were more likely than those who did not prescribe the medication to report MOUD adaptations. Among respondents reporting any MOUD adaptation, 77% made adaptations to their UDS practices. Among 513 respondents who answered COVID-19-related questions, 89% reported that the pandemic had affected the treatment and engagement of their patients. Of these respondents, 30% reported increased difficulty with patient engagement, and 45% reported that their patients preferred virtual visits during this period, whereas 18% endorsed patient preference for in-person visits. CONCLUSIONS: Telehealth and federal regulatory easements in response to the COVID-19 pandemic enabled providers to continue treating patients for opioid use disorder in 2020. The results suggest that care adaptations and changes in patient demand and engagement were common in the practices surveyed.

Addiction Medicine Practice-Based Research Network (AMNet): Assessment Tools and Quality Measures.

INTRODUCTION: The need for innovative approaches to address the opioid epidemic in the United States is widely recognized. Many challenges exist to addressing this epidemic, including the obstacles outpatient substance use treatment practices face in implementing measurement-based care (MBC), quality measurement systems, and evidence-based treatments. Also, there are insufficient opportunities for clinicians in these settings to participate in research, resulting in diminished translation of research findings into community-based practice. To address these challenges, the Addiction Medicine Practice-Based Research Network (AMNet) was developed to facilitate the uptake of MBC in outpatient practices via implementation of patient-reported assessments and quality of care performance measures to improve patient outcomes. This network will offer clinicians in outpatient settings (not incuding opioid treatment programs [OTPs]) the opportunity to participate in future substance use disorder treatment research studies. METHODS: A key step in the development of AMNet was the selection of substance use-specific assessment tools and quality of care performance measures for incorporation into the American Psychiatric Association's mental health patient registry, PsychPRO. A scoping review and multi-step consensus-based process were used to identify, review and select candidate assessment tools and quality of care performance measures for opioid use disorders (OUD) and substance use disorders (SUD). RESULTS: Following a consensus-based methodology, 12 standardized assessment tools and 3 quality of care performance measures for OUD and SUD were selected to help facilitate the implementation of MBC and quality improvement for AMNet participants. These tools were further categorized as core and optional. CONCLUSION: By offering a collection of carefully vetted assessment tools and quality measures through PsychPRO, AMNet will help participating clinicians with the systematic uptake of MBC and delivery of evidence-based treatment for patients with SUD. Also, AMNet will act as a centralized repository of data collected from patients and clinicians in non-OTP outpatient addiction medicine practices and serve as a platform for opioid treatment research.

Addiction Medicine Practice-Based Research Network (AMNet): Building Partnerships.

This column describes the collaboration among the American Psychiatric Association (APA), American Society of Addiction Medicine, Friends Research Institute, and the National Institute on Drug Abuse to create the Addiction Medicine Practice-Based Research Network (AMNet). The collaboration, which aims to address the opioid overdose epidemic in the United States, leverages the APA's clinical data registry (PsychPRO) and is recruiting office-based addiction medicine and addiction psychiatry practices for AMNet. AMNet aims to address knowledge gaps regarding patient care in such practices, facilitate performance improvement efforts, and serve as a research platform.

The Use of a Shared Services Model for Mycobacteriology Testing: Lessons Learned.

OBJECTIVES: Public health laboratories (PHLs) provide essential services in the diagnosis and surveillance of diseases of public health concern, such as tuberculosis. Maintaining access to high-quality laboratory testing is critical to continued disease detection and decline of tuberculosis cases in the United States. We investigated the practical experience of sharing tuberculosis testing services between PHLs through the Shared Services Project. METHODS: The Shared Services Project was a 9-month-long project funded through the Association of Public Health Laboratories and the Centers for Disease Control and Prevention during 2012-2013 as a one-time funding opportunity to consortiums of PHLs that proposed collaborative approaches to sharing tuberculosis laboratory services. Submitting PHLs maintained testing while simultaneously sending specimens to reference laboratories to compare turnaround times. RESULTS: During the 9-month project period, 107 Mycobacterium tuberculosis complex submissions for growth-based drug susceptibility testing and molecular detection of drug resistance testing occurred among the 3 consortiums. The median transit time for all submissions was 1.0 day. Overall, median drug susceptibility testing turnaround time (date of receipt in submitting laboratory to result) for parallel testing performed in house by submitting laboratories was 31.0 days; it was 43.0 days for reference laboratories. The median turnaround time for molecular detection of drug resistance results was 1.0 day (mean = 2.8; range, 0-14) from specimen receipt at the reference laboratories. CONCLUSIONS: The shared services model holds promise for specialized tuberculosis testing. Sharing of services requires a balance among quality, timeliness, efficiency, communication, and fiscal costs.

What are colorectal cancer survivors' preferences for dietary advice? A best-worst discrete choice experiment.

PURPOSE: Studies on healthy lifestyle interventions in survivors of colorectal cancer have been disappointing, demonstrating only modest changes. This study aims to quantify people's preferences for different aspects of dietary intervention. METHOD: A best-worst discrete choice experiment was designed and incorporated into a questionnaire including participants' characteristics and a self-assessment of lifestyle. RESULTS: The response rate was 68% and 179 questionnaires were analysed. When analysing aggregate preferences, the modes of information provision selected as the most preferred were "face-to-face" (willingness to pay (WTP) £63.97, p ≤ 0.001) and "telephone" (WTP £62.36, p < 0.001) discussions whereas group discussions were preferred least (WTP -£118.96, p ≤ 0.001). Scenarios that included hospitals were most preferred (WTP £17.94, p = 0.031), and the favoured provider was bowel cancer nurses (WTP £75.11, p ≤ 0.001). When investigating preference heterogeneity, three sub-groups were identified: Firstly, "technophiles" preferring email (WTP £239.60, p ≤ 0.001) were male, were younger and had fewer risk factors. Secondly, a "one-to-one" group had strong preference for interventions over the telephone or at their local doctors and were older (WTP £642.13, p ≤ 0.001). Finally, a "person-centred" group preferred face-to-face individual or group sessions (WTP £358.79, p < 0.001) and had a high risk lifestyle. CONCLUSION: For survivors of colorectal cancer, there is not one approach that suits all when it comes to providing dietary advice. IMPLICATIONS FOR CANCER SURVIVORS: This is important information to consider when planning healthy lifestyle interventions which include dietary advice for survivors of colorectal cancer. Aligning services to individuals' preferences has the potential to improve patient experience and outcomes by increasing uptake of healthy lifestyle advice services and promoting a more tailored approach to dietary modifications, acknowledging sub-groups of people within the total population of colorectal cancer survivors.

Reproducibility of the NEPTUNE descriptor-based scoring system on whole-slide images and histologic and ultrastructural digital images.

The multicenter Nephrotic Syndrome Study Network (NEPTUNE) digital pathology scoring system employs a novel and comprehensive methodology to document pathologic features from whole-slide images, immunofluorescence and ultrastructural digital images. To estimate inter- and intra-reader concordance of this descriptor-based approach, data from 12 pathologists (eight NEPTUNE and four non-NEPTUNE) with experience from training to 30 years were collected. A descriptor reference manual was generated and a webinar-based protocol for consensus/cross-training implemented. Intra-reader concordance for 51 glomerular descriptors was evaluated on jpeg images by seven NEPTUNE pathologists scoring 131 glomeruli three times (Tests I, II, and III), each test following a consensus webinar review. Inter-reader concordance of glomerular descriptors was evaluated in 315 glomeruli by all pathologists; interstitial fibrosis and tubular atrophy (244 cases, whole-slide images) and four ultrastructural podocyte descriptors (178 cases, jpeg images) were evaluated once by six and five pathologists, respectively. Cohen's kappa for inter-reader concordance for 48/51 glomerular descriptors with sufficient observations was moderate (0.40

Day surgery visits for dental problems.

OBJECTIVES: To fill an information gap for dental care policy stakeholders in Canada, this pilot study explored the nature of day surgery (DS) visits for dental problems in Ontario, the country's largest province. METHODS: The Canadian Institute for Health Information's National Ambulatory Care Reporting System was used, which contains demographic, diagnostic, procedural and administrative information for ambulatory care settings across Ontario. Fiscal years 2003/2004 to 2005/2006 data were included for DS visits that had a main problem coded with an International Classification of Diseases code in the range K00-K14, representing diseases of the oral cavity, salivary glands and jaws. RESULTS: During this period, approximately 75 791 persons made 79 133 DS visits for dental problems in Ontario. Proportionally, children under 5 years of age with dental caries represent the majority of DS visits. Restorations and extractions were the most frequently performed DS care procedure. CONCLUSIONS: This is the first study of its kind in Canada, and confirms many of the assumptions held about DS care for dental problems. The study also acts as a baseline for ongoing quality improvement and planning within the province of Ontario.

Emergency department visits for dental care of nontraumatic origin.

OBJECTIVES: To explore the nature of emergency department (ED) visits for dental problems of nontraumatic origin in Canada's largest province, Ontario. METHODS: The Canadian Institute for Health Information's National Ambulatory Care Reporting System was used, which contains demographic, diagnostic, procedural and administrative information from hospital-based ambulatory care settings across Ontario. Data of fiscal years 2003/04 to 2005/06 were included for emergency visits that had a main problem coded with an International Classification of Diseases - 10th edition code in the range K00-K14, representing diseases of the oral cavity, salivary glands and jaws. Volumes are presented by a number of different factors in order to describe patient and visit characteristics. RESULTS: During this period, there were a total of 141 365 ED visits for dental problems of nontraumatic origin in Ontario, representing an estimated 116 357 persons. Approximately half of all visits (54%) were made by those 20 to 44 years old, and associated with periapical abscesses and toothaches (56%). The great majority (78%) were triaged as nonurgent, and most (93%) were discharged home. CONCLUSION: ED visits for dental problems of nontraumatic origin are not insignificant. Over the study period, these visits were greater than for diabetes and hypertensive diseases. Policy efforts are needed to provide alternative options for seeking emergency dental care in Ontario.

Hospital standardized mortality ratio: the way forward in Ontario.

Variations in quality of care persist despite an increased understanding of optimal practice and an improved ability to monitor outcomes. The reporting of hospital standardized mortality ratios (HSMRs) is an important step in highlighting the need to improve quality; but, as with most measures, the HSMR is not without flaws. Intense debate in the United Kingdom and the United States, and now here in Canada, has focused too much on the shortcomings of this measure and not enough on the issue at hand. The Ontario Ministry of Health and Long-Term Care--assuming our commitment to steward the healthcare system--embraces the themes of transparency and accountability as key tools in focusing attention on system performance and quality. The analysis of HSMRs in Ontario has indicated limitations to its interpretation, similar to those observed in the Winnipeg Regional Health Authority. The HSMR may not be a specific measure of adverse events, but this does not negate its usefulness in tracking the impact of quality improvement initiatives over time; it may be considered a valuable tool among a suite of indicators. In light of this, there is an opportunity to develop better statistics, including better data and measurement frameworks, and to educate the public to facilitate accurate interpretation, which will drive improvements in practice, quality and patients' experiences.

Pharmacokinetics of oral micronized beta-estradiol in postmenopausal women receiving maintenance hemodialysis.

BACKGROUND: Although 11% of postmenopausal women with end-stage renal disease (ESRD) are prescribed hormone replacement therapy (HRT), the appropriate use remains poorly explored. Although there remains controversy surrounding the benefits of HRT, it may be of particular interest in this population, which has a high risk of bone loss and a fourfold increase in fracture risk compared to the general population. However, the appropriate dose of estrogen for use in postmenopausal women with ESRD is not known. The objective of this study was to evaluate the steady-state pharmacokinetics of oral micronized beta-estradiol in postmenopausal women with ESRD compared with postmenopausal women with normal renal function in order to determine equivalent dosing. METHODS: Six postmenopausal women with ESRD receiving maintenance hemodialysis and 6 healthy postmenopausal controls received 14 days of micronized beta-estradiol (1.0 mg for control, 0.5 mg for ESRD). Blood, urine, and dialysate samples were obtained during a dosage interval on day 14. Estradiol, estrone, albumin, and sex-hormone binding globulin (SHBG) concentrations were determined. Free estradiol concentrations were calculated using a previously described method. RESULTS: Women with ESRD had significantly lower serum albumin (610 +/- 31 micromol/L vs. 684 +/- 83 micromol/L) and SHBG (78 +/- 17 vs. 118 +/- 13 nmol/L) than control subjects. Total clearance of estradiol was not significantly different. Due to difference in binding, free estradiol concentrations were significant higher in ESRD women (53.2 +/- 17.7 pg/mL) than control women (43.5 +/- 8.7 pg/mL), despite receiving 50% of the dose. There was no significant difference in estrone concentrations. Clearance of both estradiol and estrone in the dialysate was minimal. CONCLUSION: Women with ESRD should receive approximately 50% of the dose typically prescribed to women without ESRD.