Increasing buprenorphine access for patients with chronic pain: a quality improvement initiative.

OBJECTIVE: Buprenorphine is effective for chronic pain and safer than full-agonist opioids; however, limited education about and support for buprenorphine can result in under-prescribing in primary care and reduced access in specialty pain clinics. The purpose of this quality improvement initiative was to optimize and evaluate procedures for transferring patients stable on buprenorphine for chronic pain from a specialty pain clinic back to primary care. SETTING: Eight primary care clinics within a Veterans Health Administration health care system. METHODS: A standard operating procedure for facilitated transfer of prescribing was developed after a needs assessment and was introduced during an educational session with primary care providers, and providers completed a survey assessing attitudes about buprenorphine prescribing. Success of the initiative was measured through the number of patients transferred back to primary care over the course of 18 months. RESULTS: Survey results indicated that primary care providers with previous experience prescribing buprenorphine were more likely to view buprenorphine prescribing for pain as within the scope of their practice and to endorse feeling comfortable managing a buprenorphine regimen. Providers identified systemic and educational barriers to prescribing, and they identified ongoing support from specialty pain care and primary care as a facilitator of prescribing. Metrics suggested that the standard operating procedure was generally successful in transferring and retaining eligible patients in primary care. CONCLUSION: This quality improvement initiative suggests that a facilitated transfer procedure can be useful in increasing buprenorphine prescribing for pain in primary care. Future efforts to increase primary care provider comfort and address systemic barriers to buprenorphine prescribing are needed.

A Model for Rapid Transition to Virtual Care, VA Connecticut Primary Care Response to COVID-19.

INTRODUCTION: Traditionally, health care delivery in the USA has been structured around in-person visits. The COVID-19 pandemic has forced a shift to virtual care models in order to reduce patient exposure to high-risk environments and to preserve valuable health care resources. This report describes one large primary care system's model for rapid transition to virtual care (RTVC). SETTING AND PARTICIPANTS: A RTVC model was implemented at the VA Connecticut Health Care System (VACHS), which delivers care to over 58,000 veterans. PROGRAM DESCRIPTION: The RTVC model included immediate virtual care conversion, telework expansion, implementation of virtual respiratory urgent care clinics, and development of standardized note templates. PROGRAM EVALUATION: Outcomes include the rates of primary encounter types, staff teleworking, and utilization of virtual respiratory urgent care clinics. In under 2 weeks, most encounters were transitioned from in-person to virtual care, enabling telework for over half of the medical staff. The majority of virtual visits were telephone encounters, though rates of video visits increased nearly 18-fold. DISCUSSION: The RTVC model demonstrates expeditious and sustained transition to virtual care during the COVID-19 pandemic. Our experiences help inform institutions still reliant on traditional in-person visits, and future pandemic response.

A novel approach to the program evaluation committee.

BACKGROUND: The Accreditation Council for Graduate Medical Education requires each residency program to have a Program Evaluation Committee (PEC) but does not specify how the PEC should be designed. We sought to develop a PEC that promotes resident leadership and provides actionable feedback. METHODS: Participants were residents and faculty in the Traditional Internal Medicine residency program at Yale School of Medicine (YSM). One resident and one faculty member facilitated a 1-h structured group discussion to obtain resident feedback on each rotation. PEC co-facilitators summarized the feedback in written form, then met with faculty Firm Chiefs overseeing each rotation and with residency program leadership to discuss feedback and generate action plans. This PEC process was implemented in all inpatient and outpatient rotations over a 4-year period. Upon conclusion of the second and fourth years of the PEC initiative, surveys were sent to faculty Firm Chiefs to assess their perceptions regarding the utility of the PEC format in comparison to other, more traditional forms of programmatic feedback. PEC residents and faculty were also surveyed about their experiences as PEC participants. RESULTS: The PEC process identified many common themes across inpatient and ambulatory rotations. Positives included a high caliber of teaching by faculty, highly diverse and educational patient care experiences, and a strong emphasis on interdisciplinary care. Areas for improvement included educational curricula on various rotations, interactions between medical and non-medical services, technological issues, and workflow problems. In survey assessments, PEC members viewed the PEC process as a rewarding mentorship experience that provided residents with an opportunity to engage in quality improvement and improve facilitation skills. Firm chiefs were more likely to review and make rotation changes in response to PEC feedback than to traditional written resident evaluations but preferred to receive both forms of feedback rather than either alone CONCLUSIONS: The PEC process at YSM has transformed our program's approach to feedback delivery by engaging residents in the feedback process and providing them with mentored quality improvement and leadership experiences while generating actionable feedback for program-wide change. This has led to PEC groups evaluating additional aspects of residency education.

Group Visits for Overdose Education and Naloxone Distribution in Primary Care: A Pilot Quality Improvement Initiative.

OBJECTIVE: Opioid prescribing for chronic pain significantly contributes to opioid overdose deaths in the United States. Naloxone as a take-home antidote to opioid overdose is underutilized and has not been evaluated in the high-risk chronic pain population. The objective was to increase overdose education and naloxone distribution (OEND) to high-risk patients on long-term opioid therapy for pain by utilizing group visits in primary care. DESIGN: Quality improvement intervention among two primary care clinics. SETTING: A large, academic facility within the Veterans Health Administration. SUBJECTS: Patients prescribed ≥100 mg morphine-equivalent daily dose or coprescribed opioids and benzodiazepines. METHODS: One clinic provided usual care with respect to OEND; another clinic encouraged attendance at an OEND group visit to all of its high-risk patients. RESULTS: We used attendance at group visits, prescriptions of naloxone issued, and patient satisfaction scores to evaluate this format of OEND. KEY RESULTS: Group OEND visits resulted in significantly more naloxone prescriptions than usual care. At these group visits, patients were engaged, valued the experience, and all requested a prescription for the naloxone kit. CONCLUSION: This quality improvement pilot study suggests that OEND group visits are a promising model of care.

Pilot of decision support to individualize colorectal cancer screening recommendations.

OBJECTIVES: To test the feasibility of using an electronic medical record (EMR)-based decision support system (DSS) that incorporates morbidity and frailty information to individualize colorectal cancer (CRC) screening recommendations. STUDY DESIGN: Our framework used the payoff time, defined as the minimum time until the benefits of screening exceed the harms. METHODS: Subjects were 24 patients eligible for CRC screening and 22 primary care providers (PCPs). Measures included PCP satisfaction with existing reminder systems and with decision support. RESULTS: The run-in phase, during which the intervention was inactive but its performance was verified, had 14 patients enrolled. The intervention phase, during which payoff time and life expectancy calculations were used to recommend for or against CRC screening, had 10 patients enrolled. Of the 10 patients enrolled in the intervention phase, the DSS recommended in favor of CRC screening for 6 patients. (The PCPs also recommended it for those 6 patients, although 3 refused the screening.) The DSS recommended against CRC screening for 4 patients, while the PCPs recommended against it for 3 of those 4 and ordered the screening for 1 patient. PCPs who had patients enrolled in the intervention phase indicated interest in having payoff time information for all patients eligible for CRC screening. This pilot study was small and was not powered to determine the effect of the intervention on screening behavior. CONCLUSIONS: Colorectal cancer screening involves balancing immediate harms with longer-term benefits; EMR decision support may facilitate personalized benefit/harm assessment. The payoff time framework is feasible for implementation in EMR decision support.

Improving colorectal cancer screening and care in the Veterans Affairs Healthcare system.

The Veterans Health Administration (VHA) has recently launched several nationwide initiatives to improve the quality of its colorectal cancer (CRC) screening and care. The timeliness of follow-up diagnostic tests in patients who have positive noncolonoscopic CRC screening tests is one of the target areas of these initiatives. Multiple aspects of colon cancer care are being monitored, and the degree of adherence to accepted quality measures is being assessed. The purpose of this review is to describe the background leading to these initiatives and their expected impact on CRC screening and management in the VHA.

Toward a causal model of cardiovascular responses to stress and the development of cardiovascular disease.

OBJECTIVE: Cardiovascular reactivity is hypothesized to mediate the relationship between stress and cardiovascular disease. We describe three considerations that are crucial for a causal model of cardiovascular responses to stress: the need for laboratory-life generalizability, the role of interactions between environmental exposures and individual response predispositions, and the importance of the duration of both stressor exposure and cardiovascular responding. METHODS: We illustrate current understanding of stress-cardiovascular disease relationships with examples from the human and animal psychophysiology, epidemiology, and genetics literature. RESULTS: In a causal model of reactivity, the usefulness of laboratory assessment rests on the assumption that laboratory-based cardiovascular reactivity predicts responses in the natural environment. We find only limited generalizability and suggest that cardiovascular responses to stress can be better understood when examined in the natural environment. The interaction of individual response predispositions and stressor exposures contributes to the development and progression of cardiovascular disease; stress-disease relationships could therefore be better understood if predispositions and exposures were assessed simultaneously in interactive models. Cardiovascular responses to stress are likely to be most deleterious when responses are prolonged. Responses may vary in their magnitude, frequency, and duration; however, reactivity captures only response magnitude. The assessment of anticipatory and recovery measures, with response magnitude, may therefore lead to a more useful model of the stress-disease relationship. CONCLUSIONS: A causal model of cardiovascular responses to stress should generalize to the real world, assess interactions between individual predispositions and environmental exposures, and focus on sustained pathogenic exposures and responses.

What is the white-coat effect and how should it be measured?

The white coat effect is conceived as a measure of the blood pressure response to a clinic visit, but there is no agreement as to exactly how it should be defined. The most widely used definition is the difference between the average clinic and daytime ambulatory blood pressures, but other methods that have been used include the difference between clinic and home pressures, measurements using ambulatory blood pressures only, clinic measurements only, and laboratory (reactivity) testing. Few studies have compared the different methods, but the reactivity method has reported bigger changes of blood pressure and heart rate than the others. The effect tends to be greater in older than younger patients, in women than in men, but is present to a greater or lesser degree in almost all hypertensive patients. It is diminished but not obliterated by drug treatment. It is not closely related to overall blood pressure variability, and does not predict cardiovascular risk. The white coat effect appears to be idiosyncratic to the clinic setting.

Limitations of current validation protocols for home blood pressure monitors for individual patients.

BACKGROUND: Automatic blood pressure monitoring conducted at home is increasingly used in the diagnosis and management of hypertension. We assessed the adequacy of existing British Hypertension Society (BHS) and Association for the Advancement of Medical Instrumentation (AAMI) validation standards for automatic blood pressure monitoring devices. SUBJECT AND METHODS: A theoretical study and an empirical test are presented to estimate the proportion of persons for whom a blood pressure monitor validated according to existing BHS and AAMI standards would be inaccurate. RESULTS: The results suggest that a major limitation of both protocols is the lack of attention given to the number of individual patients for whom a monitor may be inaccurate. A blood pressure monitor that meets the AAMI and BHS validation criteria may report blood pressures in error by more than 5 mmHg for more than half of the people. CONCLUSIONS: A validation standard that does not take account of the person-effects on error will lead to a substantial proportion of persons using self-monitors that are systematically inaccurate for that person.