Guidelines and Policies: Implications for Individual and Population Health.

Rising rates of prescription opioids for chronic pain from the 1990s along with a concomitant worsening overdose crisis led to rapid evaluation and public health strategies to curb problems with prescription opioids. Guideline development, grounded in solid theory but based on limited evidence that translated into rigid and discordant policies, has contributed to controversies in pain management, worsening the treatment experience for people experiencing chronic pain and highlighting existing inequities from a system clouded with systemic racism. Newer public health approaches need to evaluate root causes and be more holistic addressing inequities as well as using trauma-informed principles.

Expanding buprenorphine treatment to people experiencing homelessness through a mobile, multidisciplinary program in an urban, underserved setting.

BACKGROUND AND OBJECTIVES: Inequities in access to buprenorphine treatment remain despite measures to increase access to treatment. "Begin the Turn," a low-barrier, multidisciplinary mobile care unit with access to outreach services, counseling, case management, and buprenorphine treatment addresses these disparities in an urban setting. METHODS: Retrospective medical record review of patients during the initial 6 months of operation abstracted patient demographics and clinical data, including 10 categories of adverse childhood experiences (ACEs) using a total number of ACEs (ACE score) and measuring scores greater than or equal to 4 given higher risk of chronic disease states at this level. The study collected data in electronic data capture tools. The study assessed retention rates at 1, 3, and 5 months. RESULTS: Among the 147 individuals who received care, the mean age was 39.6 years and median onset of opioid use was 21 years of age. Among study participants, 67.3% (n = 99) reported IV use, 91.9% (n = 135) reported previous experiences with addiction treatment, and 49.7% (n = 73) had previously suffered an overdose. Adverse Childhood Experiences surveys demonstrated a mean score of 4.6 (n = 141), with 63.1% (n = 89) having a score of 4 or greater. The percentages of patients retained in care at 1, 3, and 5 months were 61.2%, 36.6%, and 27.6%, respectively. CONCLUSION AND SCIENTIFIC SIGNIFICANCE: The program serves a population with high rates of trauma and overdose. The program can serve as a model for treatment for this population.

Designing and Evaluating COVID-19 Protocols for an Office-Based Opioid Treatment Program in an Urban Underserved Setting.

BACKGROUND: Despite changing federal regulations for providing telehealth services and provision of controlled substances during the COVID-19 pandemic, there is little guidance available for office-based opioid treatment (OBOT) programs integrated into primary care settings. PURPOSE: (1) Develop disaster-preparedness protocols specific to the COVID-19 pandemic for an urban OBOT program, and (2) evaluate the impacts of the protocol and telehealth on care. METHODS: Disaster-preparedness protocols specific to the COVID-19 pandemic were developed for an urban OBOT program, implemented on March 16, 2020. Retrospective chart review compared patients from January 1, 2020 to March 13, 2020, to patients from March 16, 2020 to April 30, 2020, abstracting patient demographics and comparing show and no-show rates between studied groups. RESULTS: The disaster-preparedness protocol was developed under a deliberative process to address social issues of the urban underserved population. Of 852 visits conducted between Jan 1, 2020, and April 30, 2020, a 91.7% show rate (n = 166/181) was documented for telemedicine visits after protocol implementation compared with a 74.1% show rate (n = 497/671) for routine in-person care (P = .06) without significant differences between the study populations. The no-show rate was significantly lower after protocol implementation (8.3% vs 25.9%; P <0.05). CONCLUSIONS: OBOTs require organized workflows to continue to provide services during the COVID-19 pandemic. Telemedicine, in the face of relaxed federal regulations, has the opportunity to enhance addiction care, creating a more convenient as well as an equally effective mechanism for OBOTs to deliver care that should inform future policy.

Primary Care Practice Redesign: Challenges in Improving Behavioral Health Care for a Vulnerable Patient Population.

This study examined a program focused on integrating mental health in a family medicine practice in an economically challenged urban setting. The program included using a behavioral health technology platform, a behavioral health collaborative composed of community mental health agencies, and a community health worker (CHW). Of the 202 patients screened, 196 were used for analysis; 56% were positive for anxiety, 38% had scores consistent with moderate to severe depression, and 34% were positive for post-traumatic stress disorder. There was a statistically significant difference in the diagnosis of depression when comparing the screened group to a control group. Only 27% of patients followed through with behavioral health referrals despite navigational assistance provided by a CHW and assured access to care through a community agency engaged with the Behavioral Health Alliance. Further qualitative analysis revealed that there were complex patient factors that affected patient decision making regarding follow-up with behavioral health care.

National Partnership for Maternal Safety: Consensus Bundle on Obstetric Care for Women With Opioid Use Disorder.

The opioid epidemic is a public health crisis, and pregnancy-associated morbidity and mortality due to substance use highlights the need to prioritize substance use as a major patient safety issue. To assist health care providers with this process and mitigate the effect of substance use on maternal and fetal safety, the National Partnership for Maternal Safety within the Council on Patient Safety in Women's Health Care has created a patient safety bundle to reduce adverse maternal and neonatal health outcomes associated with substance use. The Consensus Bundle on Obstetric Care for Women with Opioid Use Disorder provides a series of evidence-based recommendations to standardize and improve the quality of health care services for pregnant and postpartum women with opioid use disorder, which should be implemented in every maternity care setting. A series of implementation resources have been created to help providers, hospitals, and health systems translate guidelines into clinical practice, and multiple state-level Perinatal Quality Collaboratives are developing quality improvement initiatives to facilitate the bundle-adoption process. Structure, process, and outcome metrics have also been developed to monitor the adoption of evidence-based practices and ensure consistency in clinical care.

A sustainable family medicine academic workforce: a study of Pennsylvania residency faculty.

BACKGROUND AND OBJECTIVES: This study determined the demographic and practice characteristics of current Pennsylvania family medicine residency faculty. METHODS: Surveys were sent electronically to program directors to distribute to their faculty members. Participants were surveyed for age, race, gender, current and completed residency training program, fellowship completion, practice track, and current practice characteristics. RESULTS: Survey response rate represented 35.3% of residency faculty in Pennsylvania. The majority represented full-time faculty (83.7%), were male (53.8%), were Caucasian (84.8%), did not enter their faculty position following residency (65.9%), had completed their residency training in Pennsylvania (57.9%), and did not complete a fellowship. While most faculty have continued inpatient and outpatient care, less than half participate in other surveyed elements of comprehensive family medicine care. CONCLUSIONS: The environment within academic family medicine and changing cultures have created a shift that the future of academic practice may need to depend on new graduates. Current demographics suggest a poorly diverse faculty with private practice experience and limited full-spectrum mentors that may have contributed to family medicine's difficulties within the academic marketplace. Creating a strong primary care workforce demands ensuring a sustainable faculty.

Increased emergency department computed tomography use for common chest symptoms without clear patient benefits.

OBJECTIVE: The aim of this study was to examine changes in the utilization of computed tomography (CT) in the evaluation of common chest symptoms and the rate of clinically significant diagnoses in emergency departments after 2004. METHODS: This study analyzed the National Hospital Ambulatory Medical Care Survey, comparing 1997 to 1999 and 2005 to 2007. Set in US emergency departments, individuals older than 14 years old were eligible. The main outcome was proportion of common chest symptom-related visits (n = 17,098) associated with a CT order before 2000 and after 2004. Secondary outcomes were the proportion of these visits associated with a clinically significant diagnosis (pulmonary embolism, acute myocardial infarction, acute coronary syndrome, heart failure, pneumonia, and pleural effusion); an incidental diagnosis such as lung mass; and a clinically nonsignificant diagnosis such as nonspecific chest pain. RESULTS: The proportion of common chest symptom-related visits associated with a CT order increased from 2.1% in 1997 to 1999 to 11.5% in 2005 to 2007 (P < .001), whereas the overall proportion of these visits associated with a clinically significant diagnosis decreased from 23.6% in 1997 to 1999 to 19.1% in 2005 to 2007 (P < .001).The rate of acute myocardial infarction diagnosis decreased from 6.6% to 3.3% (P < .001), whereas the rate of pulmonary embolism diagnosis did not change (0.33% vs. 0.47%; P = .24) from 1997 to 1999 to 2005 to 2007. The rate of incidental diagnoses did not change (0.13% vs. 0.17%; P = .69), whereas the rate of clinically nonsignificant diagnoses increased from 35.6% to 45.8% (P < .001) from 1997 to 1999 to 2005 to 2007. CONCLUSIONS: CT ordering in emergency departments for the evaluation of common chest symptoms has increased dramatically without improving the rate of pulmonary embolism or other clinically significant diagnoses. Overuse of CT exposes patients to radiation and increases health care costs without any apparent diagnostic benefit.