Brief Provider Education is Associated With Decreased ED Visits by Super-Utilizers.

INTRODUCTION: Prior studies have demonstrated that the use of opioids in an Emergency Department (ED) increases the chances of a 30-day return to the ED for similar diagnoses. Super-utilizers (SUs) of the EDs tax the ED resources, resulting in sub-optimal outcomes for these patients. Most physicians receive sub-optimal formal training on pain and opioid prescribing. These facts provide an area of improvement for administering optimal patient care in the ED. Presenting a structured curriculum on how to treat patients with pain in the ED could result in a simple, cost-effective solution to decrease provider work-overload, decrease misuse of healthcare resources, and increase the well-being of opioid-addicted patients. METHODS: The American Academy of Emergency Medicine's Model ED Pain Treatment Guidelines were presented to ED physicians at virtual and in-person department meetings at five EDs in the Midwestern United States. Retrospective (Phase I) and prospective data (Phase II) of all ED visits for each hospital were collected and de-identified. The raw data were segregated by ICD-10 codes to identify the visits made for pain diagnoses. SU was defined as any patient who visited the ED more than once for the same pain diagnosis. McNemar's test assessed the change in the number of SUs. Z-Scores assessed the change in number of visits by SUs and visits made by non-SUs between the two phases. Data were categorized by hospital and by total type of SUs based on how many visits they made. RESULTS: The data from Phase I were assessed and divided by hospital into three groups, those that used the ED more than once, more than twice, and more than three times for the same diagnosis. A statistically significant decrease (p-value = 0.0006) was noted in the group that visited the ED more than once from Phase I (n=4,413) to Phase II (n=4,109). There was a statistically significant decrease (p-value = 0.0008) in number of visits (n=268) by SUs. There was a decrease in visits made by non-SUs (n=292) but it was not statistically significant (p-value=0.9992). CONCLUSION: Opioid prescribing education was associated with decreased SUs who visited the ED more than once and in total visits made by SUs. This decrease in visits could be correlated to an estimated savings of over $1 million across five EDs with an estimated total 70,000 annual patient volume ED based on average costs of ED visits by SUs. There was no significant change in the groups of SUs who visited more than twice or more than three times. Provider opioid prescribing education may have little or no effect on some patients who may chronically use the ED for pain-related diagnoses, regardless of the training of the emergency providers.

Use of Motivational Interviewing Techniques by Student Volunteers to Reduce Substance Use in Coyote Clinic Patients.

INTRODUCTION: Nationally, free clinics report 18.5% of clients have a substance use disorder but few clinics have treatment resources on site. In 2014, 63,000 people in South Dakota needed but did not receive treatment for substance abuse. The Coyote Clinic (CC), a student-run free clinic, focuses on acute problems, making it difficult to manage and follow-up on long-term substance abuse disorders. Motivational interviewing (MI) is a style of counseling that has shown efficacy in producing change in behavior among patients who suffer from substance abuse in just one session. METHODS: A MI instructional session was given to all third-year medical students with a pre- and post-course survey to determine understanding and its application. For 21 weeks in the CC, a survey about substance use and willingness to change behavior was distributed to patients before and after the student interview. Student volunteers also responded to a post-clinic survey about their use of MI during the patient visit. RESULTS: Students showed a 17% increase in confidence in discussing substance use with patients and a 47% increase in confidence in applying MI techniques after the instructional session. At CC, 54.5% of patients reported substance use and 16.7% of those patients responded that they would consider quitting in the next month after the student interview. In the post-clinic survey, students rated an average of 4.21 out of 5 on comfort level in discussing excessive substance use. CONCLUSION: MI training expanded student volunteers' insight into treatment of substance use disorders and increased students' confidence when advising patients about substance abuse. Patients showed more willingness to change substance abuse behaviors after their student interviews. This project helps address substance use in student-run free clinics with limited resources and minimal follow up.