Brief Interventions for Suicidal Youths in Medical Settings: A Meta-Analysis.

CONTEXT: Most youths who die by suicide have interfaced with a medical system in the year preceding their death, placing outpatient medical settings on the front lines for identification, assessment, and intervention. OBJECTIVE: Review and consolidate the available literature on suicide risk screening and brief intervention with youths in outpatient medical settings and examine common outcomes. DATA SOURCES: The literature search looked at PubMed, OVID, CINAHL, ERIC, and PsychInfo databases. STUDY SELECTION: Interventions delivered in outpatient medical settings assessing and mitigating suicide risk for youths (ages 10-24). Designs included randomized controlled trials, prospective and retrospective cohort studies, and case studies. DATA EXTRACTION: Authors extracted data on rates of referral to behavioral health services, initiation/adjustment of medication, follow-up in setting of assessment, suicidal ideation at follow-up, and suicide attempts and/or crisis services visited within 1 year of initial assessment. RESULTS: There was no significant difference in subsequent suicide attempts between intervention and control groups. Analysis on subsequent crisis service could not be performed due to lack of qualifying data. Key secondary findings were decreased immediate psychiatric hospitalizations and increased mental health service use, along with mild improvement in subsequent depressive symptoms. LIMITATIONS: The review was limited by the small number of studies meeting inclusion criteria, as well as a heterogeneity of study designs and risk of bias across studies. CONCLUSIONS: Brief suicide interventions for youth in outpatient medical settings can increase identification of risk, increase access to behavioral health services, and for crisis interventions, can limit psychiatric hospitalizations.

Adolescent Female Perspectives in an Urban Safety Net: Developing an Intervention Focusing on Sexual Health and Text-Messaging.

Our goal was to develop a patient-centered text-message intervention for adolescent females in an urban safety-net health system. We conducted interviews with adolescent females to explore sexual health knowledge and inform the development of a text-messaging intervention. Focused group discussions (FGDs) verified or challenged interview themes and elicited preferences for intervention design. Forty-two females participated, including 15 interviewees and 27 FGD participants. Over half (67%) were Hispanic/Latina, 19% Black, 10% White and 5% Asian. The average age was 16 (±1.5) and 55% reported ever having sex. Participants felt susceptible to and were more concerned with preventing unintended pregnancies than sexually transmitted infections, and described more barriers to condom use than other contraceptive methods. Their input informed the development of a text-messaging intervention, which is described. This study supports the acceptability of a patient-centered texting intervention for promoting and normalizing healthy sexual behaviors among adolescent females in an urban safety-net setting.

Patient Perspectives on a Text Messaging Program to Support Asthma Management: A Qualitative Study.

Introduction. This study investigated participants' acceptance of a short messaging service (SMS) intervention designed to support asthma management, including suggestions regarding program delivery and message content. Methods. Individual and group interviews were conducted with patients from a safety-net health care system in Denver, Colorado. Eligible participants were English or Spanish speakers between the ages of 13 and 40 years, with diagnosed persistent asthma. All individual and group interviews were digitally recorded, transcribed, translated from Spanish to English (where applicable), and analyzed for thematic content by experienced analysts using established qualitative content techniques. The qualitative software package ATLAS.ti was used for data analysis and management. Results. This study included a total of 43 participants. In general, participants were receptive toward the SMS program and supported the use of tailored and interactive messages. Adolescents supported the idea of enhancing care by sending messages to a support person, such as a parent or guardian. However, adults were less receptive toward this idea. Participants also preferred directive educational messages and cues to action, while general messages reminding them of their asthma diagnosis were viewed less favorably. Implications. The results from this study will inform a randomized control trial evaluating the efficacy of the SMS intervention.

Delays in Diagnosis and Treatment of Breast Cancer: A Safety-Net Population Profile.

Background: Timely detection and treatment of breast cancer is important in optimizing survival and minimizing recurrence. Given disparities in breast cancer outcomes based on socioeconomic status, we examined time to diagnosis and treatment in a safety-net hospital. Methods: We conducted a retrospective review of all patients with breast cancer diagnosed between July 1, 2010, and June 30, 2012 (N=120). We limited our analytic sample to patients with nonrecurrent, primary stage 0-III breast cancer (N=105) and determined intervals from presentation to diagnosis, diagnosis to first treatment, last surgery to chemotherapy initiation, and last surgery to start of radiation therapy (RT). Using logistic regression, we calculated unadjusted odds of receiving timely treatment (< median time) versus more delayed treatment (≥ median time) as a function of age, language, ethnicity, insurance, Charlson comorbidity index, disease stage, method of first presentation (screening mammography vs care provider), symptoms at presentation, and type of surgical treatment. Results: Patients aged 55 to 64 years accounted for most of the sample (n=37; 35.2%). Median time from presentation to diagnosis (23 days), time from diagnosis to first treatment, and time from surgery to chemotherapy initiation fell within intervals published in the literature; median time from last surgery to start of RT was greater than recommended intervals. Factors significantly associated with longer intervals than median time included stage, method of presentation, language, surgical treatment, insurance, and ethnicity. Conclusions: Patients in this safety-net setting experienced acceptable diagnosis and treatment intervals, except for time to RT. Focused interventions that help care providers access imaging quickly for their symptomatic patients could improve time to diagnosis. Concentrating additional efforts on non-English-speaking, Hispanic patients and those who need to receive RT could improve time to treatment.

A Qualitative Study of Hospitalists' Perceptions of Patient Satisfaction Metrics on Pain Management.

Hospital initiatives to promote pain management may unintentionally contribute to excessive opioid prescribing. To better understand hospitalists' perceptions of satisfaction metrics on pain management, the authors conducted 25 interviews with hospitalists. Transcribed interviews were systematically analyzed to identify emergent themes. Hospitalists felt institutional pressure to earn high satisfaction scores for pain, which they perceived influenced practices toward opioid prescribing. They felt tying compensation to satisfaction scores commoditized pain. Hospitalists believed satisfaction would improve with increased time spent at the bedside. Focusing on methods to improve patient-physician communication, while maintaining efficiency in clinical practice, may promote both patient-centered pain management and satisfaction.

The hospitalist perspective on opioid prescribing: A qualitative analysis.

BACKGROUND: Pain is a frequent symptom among patients in the hospital. Pain management is a key quality indicator for hospitals, and hospitalists are encouraged to frequently assess and treat pain. Optimal opioid prescribing, described as safe, patient-centered, and informed opioid prescribing, may be at odds with the priorities of current hospital care, which focuses on patient-reported pain control rather than the potential long-term consequences of opioid use. OBJECTIVE: We aimed to understand physicians' attitudes, beliefs, and practices toward opioid prescribing during hospitalization and discharge. DESIGN: In-depth, semistructured interviews. SETTING: Two university hospitals, a safety-net hospital, a Veterans Affairs hospital, and a private hospital located in Denver, Colorado or Charleston, South Carolina. PARTICIPANTS: Hospitalists (N = 25). MEASUREMENTS: We systematically analyzed transcribed interviews and identified emerging themes using a team-based mixed inductive and deductive approach. RESULTS: Although hospitalists felt confident in their ability to control acute pain using opioid medications, they perceived limited success and satisfaction when managing acute exacerbations of chronic pain with opioids. Hospitalists recounted negative sentinel events that altered opioid prescribing practices in both the hospital setting and at the time of hospital discharge. Hospitalists described prescribing opioids as a pragmatic tool to facilitate hospital discharges or prevent readmissions. At times, this left them feeling conflicted about how this practice could impact the patient over the long term. CONCLUSIONS: Strategies to provide adequate pain relief to hospitalized patients, which allow hospitalists to safely and optimally prescribe opioids while maintaining current standards of efficiency, are urgently needed. Journal of Hospital Medicine 2016;11:536-542. © 2016 Society of Hospital Medicine.

Variation in primary cesarean delivery rates by individual physician within a single-hospital laborist model.

BACKGROUND: Laborist practice models are associated with lower rates of cesarean delivery than individual private practice models in several studies; however, this effect is not uniform. Further exploration of laborist models may help us better understand the observed decrease in rates of cesarean delivery in some hospitals that implement a laborist model. OBJECTIVE: Our objective was to evaluate the degree of variation in rates of primary cesarean delivery by individual laborists within a single institution that uses a laborist model. In addition, we sought to evaluate whether differences in rates of cesarean delivery resulted in different maternal or short-term neonatal outcomes. STUDY DESIGN: At this teaching institution, one laborist (either a generalist or maternal-fetal medicine attending physician) is directly responsible for labor and delivery management during each shift. No patients are followed in a private practice model nor are physicians incentivized to perform deliveries. We retrospectively identified all laborists who delivered nulliparous, term women with cephalic singletons at this institution from 2007 to 2014. Overall and individual primary cesarean delivery rates were reported as percentages with exact Pearson 95% confidence intervals. Laborists were grouped by tertile as having low, medium, or high rates of cesarean delivery. Characteristics of the women delivered, indications for cesarean delivery, and short-term neonatal outcomes were compared between these groups. A binomial regression model of cesarean delivery was estimated, where the relative rates of each laborist compared with the lowest-unadjusted laborist rate were calculated; a second model was estimated to adjust for patient-level maternal characteristics. RESULTS: Twenty laborists delivered 2224 nulliparous, term women with cephalic singletons. The overall cesarean delivery rate was 24.1% (95% confidence interval 21.4-26.8). In an unadjusted binomial model, the overall effect of individual laborist was significant (P < .001), and a 2.9-fold (1.5-5.4, P = .001) variation between the cesarean delivery rates of the greatest (35.9%) and lowest (12.5%) physicians was observed. When adjusted for hypertensive disease, gestational age at delivery, race, and maternal age, the physician effect remained overall significant (P = .0265) with the difference between physicians expanding to 3.58 (1.72-7.47, P <. 001). Between groups of laborists with low, medium, and high rates of cesarean delivery, patient demographics and clinical characteristics of the population managed were clinically similar and not different statistically. The primary indication for cesarean delivery did not differ between groups. Similarly there were no differences in short-term neonatal outcomes, including Apgar scores, arterial cord blood pH, or the incidence of neonatal encephalopathy. CONCLUSION: The 3-fold variation in cesarean delivery rates between laborists at the same institution without observed differences in patient characteristics or short-term neonatal outcomes draws attention to the impact of individual physician decision-making on cesarean delivery rates even within a laborist care model. Further exploration of the role of individual physician decision-making on cesarean rates may help to better elucidate the effect of the laborist model.