Review of Complaints to the Rhode Island Board of Medical Licensure and Discipline 2018-2020.

OBJECTIVE: This study aimed to examine the patterns of complaints filed against physicians in Rhode Island, investigate the factors associated with complaint rates and outcomes, and assess the impact of the implementation of a new Framework for Just Culture. METHODS: Complaint data from the Rhode Island Department of Health's complaint tracker and physician licensing database were analyzed for the period of 2018 to 2020. Descriptive and statistical process control analyses were conducted to assess complaint rates, investigation rates, and adverse outcomes. RESULTS: Over the three-year period, 1672 complaints were filed against Rhode Island physicians, with approximately 40% of complaints being opened for investigation. The implementation of the Framework for Just Culture coincided with a sustained decrease in the rate of complaints opened. Failure to meet the minimum standard of care was the most common allegation, and male physicians and those aged 40-50 were more likely to have complaints filed against them. CONCLUSIONS: The study highlights the importance of complaint investigations in upholding standards for medical licensure and clinical competence. The Framework for Just Culture may have influenced the investigation process, resulting in fewer investigations opened without compromising the identification of cases requiring disciplinary action. These findings provide insights into physician accountability and the need for ongoing monitoring and improvement in complaint handling systems.

Dispensed Opioid, Buprenorphine, Benzodiazepine, and Stimulant Prescriptions among Rhode Island Residents, 2017-2021.

The Rhode Island Prescription Drug Monitoring Program (PDMP) requires dispensers with an active Controlled Substance Registration to report Schedule II-V substances and opioid antagonists within 24 hours of dispensing. This database was designed to surveille diversion and identify high-risk prescribing to prevent drug related harms. Using PDMP data from January 1, 2017, to December 31, 2021, opioid, buprenorphine, stimulant, and benzodiazepine dispensing trends were explored. During this time, opioid prescriptions dispensed annually decreased by 27.3% (from 576,421 to 419,220), and benzodiazepine prescriptions dispensed annually decreased by 12.3% (552,430 to 484,496). High-risk prescribing also decreased with opioids prescriptions > 90 daily MME decreasing by 52.1% and instances of overlapping benzodiazepine and opioid prescriptions decreasing by 34.1%. Buprenorphine and stimulant dispensing have increased by 11.1% and 20.7%, respectively. Prevention interventions will continue to educate providers on appropriate prescribing practices and work to further reduce unnecessary prescribing within the state.

Review of Malpractice Settlements and Awards from 2008-2018 in Rhode Island.

OBJECTIVES: To determine the rates and characteristics of physicians with medical malpractice adverse outcomes in Rhode Island. METHODS: A descriptive epidemiologic study of medical malpractice claims from 2008-2018 aggregated by the Board of Medical Licensure and Discipline of the Rhode Island Department of Health. To examine the demographic characteristics of physician malpractice cases we reviewed 10 years of data from Rhode Island medical malpractice lawsuits that were resolved, in whole or in part, via payment to the plaintiff. RESULTS: Over this 10-year period, there were 460 such cases, 88% of which involved a male physician and 48% of which involved surgical category specialists. Few cases, 17.6% of payments, were over one million dollars, and the mean payment value across all cases was $517,104. The rate of paid claims was found to be stable over the period studied.

Rhode Island's Opioid Overdose Hospital Standards and Emergency Department Naloxone Distribution, Behavioral Counseling, and Referral to Treatment.

STUDY OBJECTIVE: We sought to determine the influence of the Levels of Care for Rhode Island Emergency Departments and Hospitals for Treating Overdose and Opioid Use Disorder (Levels of Care) on emergency department (ED) provision of take-home naloxone, behavioral counseling, and referral to treatment. METHODS: A retrospective analysis of Rhode Island ED visits for opioid overdose from 2017 to 2018 was performed using data from a statewide opioid overdose surveillance system. Changes in provision of take-home naloxone, behavioral counseling, and referral to treatment before and after Levels of Care implementation were assessed using interrupted time series analysis. We compared outcomes by hospital type using multivariable modified Poisson regression models with generalized estimating equation estimation to account for hospital-level variation. RESULTS: We analyzed 245 overdose visits prior to Levels of Care implementation (January to March 2017) and 1340 overdose visits after implementation (hospital certification to December 2018). After implementation, the proportion of patients offered naloxone increased on average by 13% (95% confidence interval [CI] 5.6% to 20.4%). Prior to implementation, the proportion of patients receiving behavioral counseling and treatment referral was declining. After implementation, this decline slowed and stabilized, and on average 18.6% more patients received behavioral counseling (95% CI 1.3% to 35.9%) and 23.1% more patients received referral to treatment (95% CI 2.7% to 43.5%). Multivariable analysis showed that after implementation, there was a significant increase in the likelihood of being offered naloxone at Level 1 (adjusted relative risk [aRR] 1.31 [95% CI 1.06 to 1.61]) and Level 3 (aRR 3.13 [95% CI 1.08 to 9.06]) hospitals and an increase in referrals for medication for opioid use disorder (from 2.5% to 17.8%) at Level 1 hospitals (RR 7.73 [95% CI 3.22 to 18.55]). Despite these increases, less than half of the patients treated for an opioid overdose received behavioral counseling or referral to treatment CONCLUSION: The establishment of ED policies for treatment and services after opioid overdose improved naloxone distribution, behavioral counseling, and referral to treatment at hospitals without previously established opioid overdose services. Future investigations are needed to better characterize implementation barriers and evaluate policy influence on patient outcomes.

Initial Opioid Prescription and Number Needed to Harm.

Prescription opioids are an important step in the development of persistent opioid use. Our study estimates the change in long-term opioid use before and after a 2017 regulatory update on acute pain prescribing. Prescribing information was abstracted from the Rhode Island Prescription Drug Monitoring Program (PDMP). Using the changed rates of initial opioid prescriptions of 8 or more days, and a calculated Number Needed to Harm for prescriptions of that duration, the rates of long-term opioid use were estimated decrease by 111 long-term opioid users per month.

Review of Rhode Island Physician Loss-of-Licensure Cases, 2009-2019.

Disciplinary actions against physicians are uncommon, and loss of license is less common. This unmatched, case-control, and descriptive study reviews disciplinary actions involving physician loss-of-license cases from January 1, 2009, to December 31, 2019. There were 82 physician loss-of-license cases involving 66 physicians, which were categorized by age, sex, and specialty and were compared to 4,347 non-disciplined controls. In this study, males (OR 4.69, p<0.001) were associated with an increased risk of loss of license; age was a separate risk factor (OR 1.24, p<0.05). Preventive strategies are discussed to reduce future physician loss of license.

Prescription Opioid Prescribing in Western Europe and the United States.

Pain is universal, yet the prevalence of overdose and treatment of pain varies significantly between the United States (US) and Western Europe. Overdose deaths are seven times more common in the US compared to Western Europe. Cultural perceptions of pain, perception and treatment of opioid use disorder, pharmaceutical advertising, and rates and regulation of prescribing of opioids represent examples of factors that may be related to such differences between the US and Western Europe. As Rhode Island continues to battle the devastating and well-documented national opioid overdose epidemic, we should consider how cultural, regulatory differences, and economic factors may influence pain and its treatment.

Multidisciplinary Team Reviews of Drug Overdose Deaths and the Use of Minigrants to Advance Recommendations: A Statewide Pilot in Rhode Island.

CONTEXT: Rhode Island has been significantly impacted by the opioid epidemic, ranking 11th in unintentional drug overdose rates in the United States in 2017. Illicit fentanyl was involved in the majority of these deaths. PROGRAM: To enhance surveillance of this epidemic, the RI Department of Health piloted in-depth, multidisciplinary, and multiagency team reviews of drug overdose deaths. The goals were to identify gaps in policies and programming and develop recommendations to prevent future deaths. Time-sensitive minigrants were offered to nonprofit organizations as a novel way to further the recommendations put forth from these reviews. IMPLEMENTATION: Legal agreements between select state agencies and institutions enabled broad team representation and the sharing of information during each meeting. Reviews, revolving around a common theme, were conducted for up to 10 deaths each quarter. Recommendations for prevention were generated by the team and summarized in a report to the Governor's Overdose Prevention and Intervention Task Force and the public within 1 month of each meeting. Announcements of minigrant opportunities and funding to advance the community-specific recommendations were paired with each meeting. EVALUATION: From November 2016 through May 2018, the pilot team convened 7 times, generated 78 recommendations, and distributed 31 minigrants. Early process evaluations of these grants have shown positive impact within local environments. Following the pilot phase, state legislation for these reviews was passed in June 2018. DISCUSSION: The RI Department of Health was able to successfully pilot a multidisciplinary review process for overdose deaths and has recently institutionalized this process through legislation. The successful implementation of many of the team's community-oriented recommendations, supported through a minigrant process, highlights the impact that small financial investments can have to address the opioid epidemic and may be a model for other jurisdictions seeking to advance recommendations from these types of reviews.

Impact of State Regulations on Initial Opioid Prescribing Behavior in Rhode Island.

The opioid epidemic presents an urgent public health problem. Rhode Island has enacted comprehensive rules to address primary prevention of opioid overdose. This study evaluates the efficacy of those regulations in altering prescribing behavior, specifically regarding the initial prescription. Using data extracted from the Rhode Island Prescription Drug Monitoring Program (PDMP), before and after the publication of updated acute pain management regulations, we studied the rate of opioid prescribing using statistical process control (SPC) charts and found that the rate of prescribing unsafe doses of opioids, more than 30 morphine milligram equivalents (MMEs) per day or more than 20 doses to opioid naïve patients, decreased significantly.

Review of Boundary Violations in Rhode Island, 2012-2018.

Boundary violations are serious occurrences that result in a breach of the physician-patient relationship. Boundary violations are regulated by the Rhode Island Board of Medical Licensure and Discipline (Board). A review of all disciplinary actions from 2012 through 2018 involving physicians found boundary violations relating to sexual misconduct the most common boundary violations. All disciplinary actions that pertained to boundary violations were isolated, and trends regarding gender, medical specialty, and outcome of action were assessed. Sexual boundary violations (n=15) represented 94% of all boundary violations during this time period. Psychiatrists (31.3%), internists (25%) and family medicine physicians (18.8%) were the most common specialties of those who had boundary issues. Loss of license occurred for all physicians who had sexual intercourse with a patient. Reinstatement of license was possible for some physicians after a comprehensive forensic psychiatry evaluation. Physicians are reminded of the ethical obligations we have to our patients and the profession and to maintain a professional relationship with their patients at all times. This type of professional misconduct is preventable and avoids injury to patients and to the medical profession. [Full article available at http://rimed.org/rimedicaljournal-2019-03.asp].

Emergency Department and Hospital Care for Opioid Use Disorder: Implementation of Statewide Standards in Rhode Island, 2017-2018.

In March 2017, Rhode Island released treatment standards for care of adult patients with opioid use disorder. These standards prescribe three levels of hospital and emergency department treatment and prevention of opioid use disorder and opioid overdose and mechanisms for referral to treatment and epidemiological surveillance. By June 2018, all Rhode Island licensed acute care facilities had implemented policies meeting the standards' requirements. This policy has standardized care for opioid use disorder, enhanced opioid overdose surveillance and response, and expanded linkage to peer recovery support, naloxone, and medication for opioid use disorder.

State Unintentional Drug Overdose Reporting Surveillance: Opioid Overdose Deaths and Characteristics in Rhode Island.

Unintentional opioid overdoses are a growing public health epidemic in the United States. Rhode Island is also faced with a challenging crisis of drug overdose deaths. The State Unintentional Drug Overdose Reporting Surveillance (SUDORS) data from the second half of 2016 were used to present opioid overdose deaths and characteristics in Rhode Island. During July-December 2016, 142 individuals died of opioid overdose in Rhode Island. People who died by opioid overdose were more likely to be 25-65 years old, male, and non-Hispanic white. The most common precipitating circumstances were substance abuse (88%), current mental health problems (43%), and physical health problems (27.5%). Over 83% of decedents had 2 or more substances attribute to causing their death, with fentanyl (71.1%) as the most common substance. Only 36.6% of decedents had naloxone administered. Fatal opioid overdose data are important for understanding this public health crisis and can guide overdose intervention efforts.

Rhode Island Unintentional Drug Overdose Death Trends and Ranking - Office of the State Medical Examiners Database.

[Full article available at http://rimed.org/rimedicaljournal-2018-02.asp].

Can Emergency Department, Hospital Discharge, and Death Data Be Used to Monitor Burden of Drug Overdose in Rhode Island?

CONTEXT: Drug overdoses are a growing public health problem in the United States. Rhode Island is also confronted with a serious epidemic of drug overdose deaths and ranks sixth worst in the United States for age-adjusted drug overdose death rate. OBJECTIVE: To monitor trends of drug overdose-related emergency department (ED) visits, hospitalizations, and deaths and classify the drug overdoses by demographics, discharge status, intent, and specific drug involved to plan for health care resource allocation, mental health services, drug abuse treatment, prevention, and policies. DESIGN: Cross-sectional study. SETTING: The 2005-2014 ED, hospital discharge, and death data were used for this study. MAIN OUTCOME MEASURE: Age-adjusted rates were calculated by using age-specific Rhode Island 2010 standard population. Healthcare Cost and Utilization Project cost-to-charge ratios were used to convert total hospital charges to costs. The descriptive analysis was performed. RESULTS: Hospitalizations generally represent the most severe cases; there are substantially fewer cases than are seen in the ED, and their characteristics are different from ED visits. More than half of the ED cases were an unintentional injury by drug overdose, but more than half of the hospital discharge data cases were a suicide/self-inflicted injury by drug overdose. There were typically much more females than males that result in a hospital admission. In Rhode Island, there were 249 drug overdose deaths in 2014. Drug overdose fatalities were more likely to be young, male, white, and those who reside in suburban regions. IMPLICATIONS: Nonfatal and fatal drug overdose data are important for understanding the scope, incidence, and breadth of this public health epidemic and can guide overdose intervention efforts. In Rhode Island, policy makers can use drug overdose data to target high-risk subpopulations to reduce overdose injuries and fatalities. The Rhode Island study can be shared with other states. CONCLUSIONS: Regardless of the type of drug, overdoses remain a public health crisis in Rhode Island. It is a dynamic epidemic and needs partnership among public health, behavioral health, public safety, clinic, pharmacy, and communities. The ability to track drug overdose in real time will be an essential tool to respond to the constantly evolving drug overdose epidemic in Rhode Island quickly and effectively.

Rhode Island Board of Medical Licensure and Discipline: Illustration of the disciplinary process as it pertains to cases involving opioid prescribing.

Prescription-drug overuse/overdose and misuse is an important and pivotal issue to state medical boards. This is an illustration of how some cases involving overprescribing of opioids have been addressed by the Rhode Island Board of Medical Licensure and Discipline.