Disparity in Receipt and Utilization of Telecommunicator CPR Instruction.

Introduction: Telecommunicator Assisted Cardiopulmonary Resuscitation (T-CPR) is independently associated with improved survival and improved functional outcome after adult Out of Hospital Cardiac Arrest (OHCA). The objective of this study was to evaluate whether there are racial and socioeconomic disparities in the provision of T-CPR instruction and subsequent CPR performance. Methods: We performed a retrospective review of a convenience sample of EMS agencies throughout the United States that utilized the Cardiac Arrest Registry to Enhance Survival (CARES) dispatch registry during the period 1/2014-12/2017. Data were collected by dispatch agencies after review of 9-1-1 OHCA audio recordings. Elements related to dispatcher CPR instruction, barriers to bystander CPR (BCPR) performance, patient race (White, Black, Hispanic-Latino, or other) and Utstein data were captured from the CARES database. These data were merged with census tract data from incident locations. The effects of race and income (Socioeconomic status, SES) on outcome were analyzed using multilevel logistic regression. Results: A total of 3,807 cases were identified from 37 dispatch agencies in 6 states. The sample was predominantly White (57.5%) and male (64.9%) with an average age of 60.3 ± 19.9. In the adjusted analysis, there were no differences in the odds of receiving CPR instruction by race (black vs white), OR = 0.96 (95% CI. 0.70, 1.32) or for increased income, (OR = 1.00, 95% CI 0.99, 1.02). There was a significant difference in receipt of T-CPR instruction by patient age, OR = 0.99 (95% CI, 0.98, 0.99). Subsequent utilization of T-CPR instruction to perform BCPR was less likely for patients that had a lower income, OR = 1.03 (95% CI 1.01, 1.05). There was also a decreased rate of BCPR provision by patient age OR = 0.99 (95% CI, 0.99, 1.00), but there was no difference in rate of BCPR provision by race, OR = 0.86 (95% CI 0.61, 1.23). Conclusion: We identified differences in age but not race or SES in the provision of T-CPR instruction by dispatch centers. We also identified decreased CPR provision by age and income after receipt of T-CPR instructions. In this sample, we found no evidence of racial disparities in the provision of T-CPR instruction or subsequent provision of BCPR.

Evaluating Dispatch-Assisted CPR Using the CARES Registry.

OBJECTIVES: Dispatch-assisted cardiopulmonary resuscitation (DA-CPR) has been shown to improve cardiac arrest survival. Recent literature has proposed dispatch metrics for provision of this intervention. Our objectives are to: use the Cardiac Arrest Registry to Enhance Survival (CARES) to compare current practice to proposed DA-CPR guidelines; describe barriers to DA-CPR; and assess the association of DA-CPR with out-of-hospital cardiac arrest (OHCA) survival. METHODS: We reviewed data from structured dispatch reviews of 911 OHCA calls from 1/1/14-12/31/15. Dispatch data including whether dispatch CPR instruction was given, and time intervals to CPR instruction and provision were linked with OHCA data elements from field cardiac arrest process and outcome data. Descriptive data on barriers to dispatch-caller instruction and measures of dispatcher performance were calculated. We compared outcome of patients who received bystander CPR prior to the 911 call (BCPR), after dispatcher CPR instructions (DA-CPR), and not until Emergency Medical Services (EMS) arrival (no BCPR). RESULTS: We identified 3335 cases from 32 dispatch agencies in 9 states that had dispatch and outcome data. CPR was performed prior to the 911 call by a bystander in 496 (14.9%) cases. Of all calls where the dispatcher talked to a bystander, dispatchers recognized cardiac arrest in 82.9% cases (1514/1827), with 31.6% calls recognized in <60 seconds. DA-CPR instructions were initiated in most (1320/1514, 87.2%) cases, and cardiac compressions were initiated in 73.7% (973/1320). DA-CPR was performed < two minutes in 21.4% of cases. In a multivariable analysis, BCPR (CPR prior to EMS arrival without instructions given) was associated with significantly improved patient survival (OR = 1.49, 95% CI 1.09, 2.04), and DA-CPR a non-significant improvement in survival to discharge (OR = 1.19, 95% CI 0.91, 1.56). CONCLUSIONS: Temporal measures of dispatch performance were substantially below proposed national standards. In this population, OHCA was frequently recognized and DA-CPR performed but was not associated with a significant improvement in survival.

Sexual Partners of Street-Based Female Sex Workers in St. Petersburg, Russia: A Model of Partnership Characteristics as a Basis for Further Research.

Street-based sex work in Russia, as in many countries, carries with it a high risk for violence and the transmission of infectious diseases. The male partners of female sex workers are both cause and recipient of such risks. Because little is known about the men, we undertook a preliminary study to determine the feasibility of recruiting and interviewing them, develop typologies that describe partners, and derive hypotheses for further study and risk reduction intervention projects. We were able to conduct open-ended, qualitative interviews with street-based sex workers and, largely through these contacts, their male partners. To these data, we added interviews with social work and medical experts who engage with the sex workers. The text of interviews from 37 respondents were analyzed to identify commonly mentioned partner characteristics in five distinct domains: sociodemographics, behavioral patterns of the partners, motivations in seeking sex services, levels of partner engagement with the sex workers, and the social circumstances that moderate the engagement. Four of the five domains (all but sociodemographics) proved useful in identifying typologies that were best described as populated points in a matrix generated from the intersection of the four domains. The data were too limited to specify which of the points in the matrix are most common, but the points populated are useful in generating hypotheses for further study and in identifying potential avenues for risk reduction interventions.

Chronic pain, addiction severity, and misuse of opioids in Cumberland County, Maine.

BACKGROUND: Few studies have examined the relationship between chronic pain and opioid abuse in non-clinical populations. We sought to investigate this in a street-recruited sample of active opioid abusers in Cumberland County, Maine, USA, a locale that had experienced substantial increases in opioid abuse. METHODS: A community-based sample was recruited using respondent-driven sampling. Participants were screened to identify those who had consumed illicit opioids in the prior month and administered a structured survey that included the Addiction Severity Index (ASI) and Brief Pain Inventory® (BPI). RESULTS: More than 40% of the 237 individuals reported recurring pain that interfered with daily living. For more than three-quarters of those reporting chronic pain, opioid misuse preceded the onset of chronic pain. The order of onset was not associated with differences in sociodemographic, current levels of drug misuse, or ASI and BPI scores. BPI scores were associated with medical and psychological ASI domains. Compared to those not reporting chronic pain, those doing so were more likely to have a regular physician but were more likely to report difficulty gaining admission to substance abuse treatment programs. CONCLUSION: Chronic pain was a common co-occurring condition among individuals misusing opioids. Better efforts are needed to integrate pain management and substance abuse treatment for this population.

Opioids, chronic pain, and addiction in primary care.

UNLABELLED: Research has largely ignored the systematic examination of physicians' attitudes towards providing care for patients with chronic noncancer pain. The objective of this study was to identify barriers and facilitators to opioid treatment of chronic noncancer pain patients by office-based medical providers. We used a qualitative study design using individual and group interviews. Participants were 23 office-based physicians in New England. Interviews were audiotaped, transcribed, and systematically coded by a multidisciplinary team using the constant comparative method. Physician barriers included absence of objective or physiological measures of pain; lack of expertise in the treatment of chronic pain and coexisting disorders, including addiction; lack of interest in pain management; patients' aberrant behaviors; and physicians' attitudes toward prescribing opioid analgesics. Physician facilitators included promoting continuity of patient care and the use of opioid agreements. Physicians' perceptions of patient-related barriers included lack of physician responsiveness to patients' pain reports, negative attitudes toward opioid analgesics, concerns about cost, and patients' low motivation for pain treatment. Perceived logistical barriers included lack of appropriate pain management and addiction referral options, limited information regarding diagnostic workup, limited insurance coverage for pain management services, limited ancillary support for physicians, and insufficient time. Addressing these barriers to pain treatment will be crucial to improving pain management service delivery. PERSPECTIVE: This article demonstrates that perceived barriers to treating patients with chronic noncancer pain are common among office-based physicians. Addressing these barriers in physician training and in existing office-based programs might benefit both noncancer chronic pain patients and their medical providers.

Expanded access to naloxone: options for critical response to the epidemic of opioid overdose mortality.

The United States is in the midst of a prolonged and growing epidemic of accidental and preventable deaths associated with overdoses of licit and illicit opioids. For more than 3 decades, naloxone has been used by emergency medical personnel to pharmacologically reverse overdoses. The peers or family members of overdose victims, however, are most often the actual first responders and are best positioned to intervene within an hour of the onset of overdose symptoms. Data from recent pilot programs demonstrate that lay persons are consistently successful in safely administering naloxone and reversing opioid overdose. Current evidence supports the extensive scaleup of access to naloxone. We present advantages and limitations associated with a range of possible policy and program responses.

Integrating buprenorphine treatment into office-based practice: a qualitative study.

BACKGROUND: Despite the availability and demonstrated effectiveness of office-based buprenorphine maintenance treatment (BMT), the systematic examination of physicians' attitudes towards this new medical practice has been largely neglected. OBJECTIVE: To identify facilitators and barriers to the potential or actual implementation of BMT by office-based medical providers. DESIGN: Qualitative study using individual and group semi-structured interviews. PARTICIPANTS: Twenty-three practicing office-based physicians in New England. APPROACH: Interviews were audiotaped, transcribed, and entered into a qualitative software program. The transcripts were thematically coded using the constant comparative method by a multidisciplinary team. RESULTS: Eighty percent of the physicians were white; 55% were women. The mean number of years since graduating medical school was 14 (SD = 10). The primary areas of clinical specialization were internal medicine (50%), infectious disease (20%), and addiction medicine (15%). Physicians identified physician, patient, and logistical factors that would either facilitate or serve as a barrier to their integration of BMT into clinical practice. Physician facilitators included promoting continuity of patient care, positive perceptions of BMT, and viewing BMT as a positive alternative to methadone maintenance. Physician barriers included competing activities, lack of interest, and lack of expertise in addiction treatment. Physicians' perceptions of patient-related barriers included concerns about confidentiality and cost, and low motivation for treatment. Perceived logistical barriers included lack of remuneration for BMT, limited ancillary support for physicians, not enough time, and a perceived low prevalence of opioid dependence in physicians' practices. CONCLUSIONS: Addressing physicians' perceptions of facilitators and barriers to BMT is crucial to supporting the further expansion of BMT into primary care and office-based practices.

Assessment of self-reported sexual behavior and condom use among female sex workers in India using a polling box approach: a preliminary report.

BACKGROUND: The accuracy of behavioral data related to risk for HIV and other sexually transmitted infections is prone to misreporting because of social desirability effects. Because computer-assisted approaches are not always feasible, a noncomputerized interview method for reducing social desirability effects is needed. The previous performance of alternative methods has been limited to aggregate data or constrained by the simplicity of dichotomous-only responses. We designed and tested a "polling box" method for case-attributable, multiple-response survey items in a low literacy population. METHODS: A cross-sectional survey was conducted with 812 female sex workers in Andhra Pradesh, India. For a subset of questions embedded in a face-to-face survey questionnaire, every third participant was provided graphical response cards upon which to mark their answer and place in a polling box outside the view of the interviewer. Multiple logistic regression analysis was used to test for response differences to questions about socially undesirable, socially desirable, or sensitivity-neutral behaviors in the 2 interview methods. RESULTS: Polling box participants demonstrated higher reporting of risky sexual behaviors and lower reporting of condom use, with no conclusive response patterns among sensitivity-neutral items. CONCLUSION: Our findings suggest that the polling box approach provides a promising technique for improving the accurate reporting of sensitive behaviors among a low-literacy population in a resource poor setting. Additional research is needed to test logistical adaptations of the polling box approach.

Strengthening drug policy and practice through ethics engagement: an old challenge for a new harm reduction.

Harm reduction proponents aim to identify and support policies and programmes that moderate or decrease the deleterious consequences of illicit drug use. While harm reduction is clearly a value-based response to drugs, for many, 'ethics' merely represent institutional research and professional practice regulations to be satisfied, subjective moral claims, or philosophy that is too abstract to offer tangible benefits in keeping with the pragmatism of harm reduction. In this paper we revisit the relationship between harm reduction and ethics, reframe ethics as a pragmatic concern for all of harm reduction, and argue that greater attention to the actual values and beliefs underpinning harm reduction can help to enhance policy, practice and research outcomes. Examples are given of early progress in this area to illustrate possible features of ethics engagement in harm reduction, and existing ethics materials are highlighted as suitable supporting resources for applied ethical decision-making in this field.

Illicit use of opioids: is OxyContin a "gateway drug"?

This study examines whether individuals who engage in illicit, non-medical use of OxyContin are distinguishable from other non-medical users of opioids and whether OxyContin serves as a "gateway" to heroin and/or injection drug use. The study sample included active nonmedical users of opioids, who are 16 years or older and residents of Cumberland County, Maine. Possible associations between type of opioid used and behavioral and descriptive variables were assessed. The study sample was predominantly urban-dwelling, male, Caucasian, and economically disadvantaged. OxyContin users could only be distinguished from heroin users (cf non-heroin opioid users). Polyopioid use within the first year of initiation was associated with quicker progression to heroin and injection drug use.

Lower injection-related HIV-1 risk associated with participation in a harm reduction program in Kazan, Russia.

This study was carried out to investigate the extent of unsafe practices associated with participation in a harm reduction program in Kazan, Russian Federation. In this cross-sectional study a convenience sample of active drug injectors encountered by the field outreach teams was interviewed. Demographic data and information on injection drug use were obtained using a structured survey instrument. Comparisons between program clients and newly encountered individuals not yet engaged by the program were made. Clients were divided into four groups based on the duration and intensity of their interaction with the program. Clients were found to be less likely than newly encountered injectors to give away or use previously used syringes, more likely to have used a new syringe the last time they injected with others, and more likely to be able to anticipate their need to acquire new syringes. However, the sharing of nonsyringe injection paraphernalia was no different between clients and newly encountered injectors. Despite the limitations of a cross-sectional study, it appears that engagement with the harm reduction program in Kazan was associated with reduction in many aspects of unsafe injecting.

Perceived needs for geriatric education by medical students, internal medicine residents and faculty.

CONTEXT: Traditional methods of setting curricular guidelines using experts or consensus panels may miss important areas of knowledge, skills, and attitudes that need to be addressed in the training of medical students and residents. OBJECTIVE: To seek input from medical students and internal medicine residents ("trainees") on their perception of their needs for training in Geriatrics. DESIGN: Two assessment methods were used (1) focus groups with students and residents were conducted by professional facilitators and the transcripts analyzed for areas of agreement and divergence and (2) geriatric medicine experts and ward attendings were surveyed to examine training gaps raised by trainees during Geriatric Guest Attending Rounds. RESULTS: Trainees perceived training gaps in caring for elderly patients in the areas of (1) recognizing and addressing the complex, multifactorial nature of illness; (2) setting priorities and goals for work-up and intervention; (3) communication with families and with patients with cognitive disorders; (4) assessment of a patient for discharge from the hospital and the services at different sites in which patients may receive care. They recounted feeling overwhelmed by complex patients and social situations while acknowledging the special aspects of connecting with older patients. The gaps identified by trainees differ from and complement the curriculum guidelines set by expert recommendations. CONCLUSION: Trainees identified gaps in skills and knowledge leading to trainee frustration and potentially adverse outcomes in caring for elderly patients. Development of curriculum guidelines should include assessment of trainees' perceived learning needs.

Secondary syringe exchange as a model for HIV prevention programs in the Russian Federation.

Effective prevention of syringe-borne transmission of HIV and the hepatitis viruses can be undermined if contact between injection drug users and the staff of prevention programs is impeded by police harassment, limited program resources, and the absence of an open "drug scene." All these are commonplace in the Russian Federation. In response, "Project Renewal," the harm reduction program of the AIDS Prevention and Control Center of the Tatarstan Ministry of Health in Kazan, has created a hybrid syringe exchange program that as its primary focus recruited and trained volunteers to provide secondary syringe exchange. To compensate for operational barriers, the program staff identified private venues and trained responsible individuals to work through their own and related networks of injectors to provide clean syringes, other harm reduction supplies, and educational materials, while facilitating the collection and removal of used and potentially contaminated syringes. Program staff developed a detailed set of tracking instruments to monitor, on a daily and weekly basis, the locations and types of contacts and the dissemination of trainings and materials to ensure that the secondary distribution network reaches its target audience. Data show that these secondary exchange sites have proven more productive than the primary mobile and fixed-site syringe exchanges in Kazan. Beginning in 2001, Project Renewal has trained other harm reduction programs in the Russian Federation to use this model of reaching injectors, identifying and training volunteers, and monitoring results of secondary syringe exchange.

Perceptions of physicians on the barriers and facilitators to integrating fall risk evaluation and management into practice.

BACKGROUND: Falls are common, treatable, and result in considerable morbidity in older adults. However, fall risk factor evaluation and management targeted at high-risk patients is largely neglected in clinical practice. OBJECTIVE: To identify barriers and facilitators to the implementation of fall risk management by primary care providers. DESIGN: Qualitative study using a semi-structured interview. PARTICIPANTS: Primary care providers who received an academic outreach visit. APPROACH: Self-reported facilitators and barriers to evaluating and managing fall risk in older patients. RESULTS: Physician factors, logistical factors, and patient factors intersect to either facilitate or impede fall risk evaluation and management by primary care providers. Physician factors include awareness, competing risks, appropriateness of referrals, training, and tie-in to familiar activities. Logistical factors include availability of transportation, time requirements of immobile patients, reimbursement, scheduling, family involvement, and utilization of other health care providers. Physicians' perceptions of patient factors include reporting, attitudes toward medication, and positive feedback. CONCLUSION: Strategies to improve the adoption of fall risk evaluation and management in primary care should address the specific physician, logistical, and patient barriers perceived by physicians who had received an informative, motivational intervention to assess and manage falls among their patients.