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Savitz ST, Stevens MA, Nath B, D’Onofrio G, Melnick ER, Jeffery MM. Trends in the Prescribing of Buprenorphine for Opioid Use Disorder, 2019-2023. Mayo Clin Proc Innov Qual Outcomes 2024; 8:308-320. [PMID: 38841599 PMCID: PMC11152959 DOI: 10.1016/j.mayocpiqo.2024.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024] Open
Abstract
Objective To evaluate whether access to buprenorphine to treat opioid use disorder (OUD) was associated with the coronavirus disease pandemic, the relaxation of training requirements to obtain an X-Waiver to prescribe buprenorphine (April 2021), and the removal of the X-Waiver (December 2022). Patients and Methods The OptumLabs Data Warehouse, which includes claims from Commercial and Medicare Advantage enrollees, was used to evaluate trends in prescription fills from January 1, 2019, to June 30, 2023. We compared fill patterns of buprenorphine for OUD with acamprosate to treat alcohol use disorder and naltrexone to treat alcohol use disorder or OUD. We evaluated trends in the rate ratio (RR) of overall fills; RR by days supply; distribution of fills by daily dose; and distribution of fills by prescriber type. Results Coronavirus disease (RR, 1.06; 95% CI, 1.01-1.11) was associated with a slightly increased rate of fills for Commercial enrollees but not overall or for Medicare Advantage enrollees. There were also no significant increases (P>0.05) associated with the change in training requirements or removal of the X-Waiver. Over the study period, there was an increasing share of fills for 16+ mg for Commercial enrollees, and buprenorphine prescribers were more likely to be advanced practice nurses or physician assistants. Conclusion We did not find meaningful improvement in access in response to coronavirus disease or the changes in the X-Waiver. These findings suggest that interventions beyond removing the X-Waiver may be needed to improve buprenorphine access.
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Affiliation(s)
- Samuel T. Savitz
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN
| | - Maria A. Stevens
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN
| | - Bidisha Nath
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT
| | - Gail D’Onofrio
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT
| | - Edward R. Melnick
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT
- Department of Biostatistics, Yale School of Public Health, New Haven, CT
| | - Molly M. Jeffery
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN
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Austin EE, Cheek C, Richardson L, Testa L, Dominello A, Long JC, Carrigan A, Ellis LA, Norman A, Murphy M, Smith K, Gillies D, Clay-Williams R. Improving emergency department care for adults presenting with mental illness: a systematic review of strategies and their impact on outcomes, experience, and performance. Front Psychiatry 2024; 15:1368129. [PMID: 38487586 PMCID: PMC10937575 DOI: 10.3389/fpsyt.2024.1368129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 02/08/2024] [Indexed: 03/17/2024] Open
Abstract
Background Care delivery for the increasing number of people presenting at hospital emergency departments (EDs) with mental illness is a challenging issue. This review aimed to synthesise the research evidence associated with strategies used to improve ED care delivery outcomes, experience, and performance for adults presenting with mental illness. Method We systematically reviewed the evidence regarding the effects of ED-based interventions for mental illness on patient outcomes, patient experience, and system performance, using a comprehensive search strategy designed to identify published empirical studies. Systematic searches in Scopus, Ovid Embase, CINAHL, and Medline were conducted in September 2023 (from inception; review protocol was prospectively registered in Prospero CRD42023466062). Eligibility criteria were as follows: (1) primary research study, published in English; and (2) (a) reported an implemented model of care or system change within the hospital ED context, (b) focused on adult mental illness presentations, and (c) evaluated system performance, patient outcomes, patient experience, or staff experience. Pairs of reviewers independently assessed study titles, abstracts, and full texts according to pre-established inclusion criteria with discrepancies resolved by a third reviewer. Independent reviewers extracted data from the included papers using Covidence (2023), and the quality of included studies was assessed using the Joanna Briggs Institute suite of critical appraisal tools. Results A narrative synthesis was performed on the included 46 studies, comprising pre-post (n = 23), quasi-experimental (n = 6), descriptive (n = 6), randomised controlled trial (RCT; n = 3), cohort (n = 2), cross-sectional (n = 2), qualitative (n = 2), realist evaluation (n = 1), and time series analysis studies (n = 1). Eleven articles focused on presentations related to substance use disorder presentation, 9 focused on suicide and deliberate self-harm presentations, and 26 reported mental illness presentations in general. Strategies reported include models of care (e.g., ED-initiated Medications for Opioid Use Disorder, ED-initiated social support, and deliberate self-harm), decision support tools, discharge and transfer refinements, case management, adjustments to liaison psychiatry services, telepsychiatry, changes to roles and rostering, environmental changes (e.g., specialised units within the ED), education, creation of multidisciplinary teams, and care standardisations. System performance measures were reported in 33 studies (72%), with fewer studies reporting measures of patient outcomes (n = 19, 41%), patient experience (n = 10, 22%), or staff experience (n = 14, 30%). Few interventions reported outcomes across all four domains. Heterogeneity in study samples, strategies, and evaluated outcomes makes adopting existing strategies challenging. Conclusion Care for mental illness is complex, particularly in the emergency setting. Strategies to provide care must align ED system goals with patient goals and staff experience.
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Affiliation(s)
- Elizabeth E. Austin
- The Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Science, Macquarie University, Macquarie, NSW, Australia
| | - Colleen Cheek
- The Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Science, Macquarie University, Macquarie, NSW, Australia
| | - Lieke Richardson
- The Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Science, Macquarie University, Macquarie, NSW, Australia
| | - Luke Testa
- The Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Science, Macquarie University, Macquarie, NSW, Australia
| | - Amanda Dominello
- The Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Science, Macquarie University, Macquarie, NSW, Australia
| | - Janet C. Long
- The Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Science, Macquarie University, Macquarie, NSW, Australia
| | - Ann Carrigan
- The Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Science, Macquarie University, Macquarie, NSW, Australia
| | - Louise A. Ellis
- The Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Science, Macquarie University, Macquarie, NSW, Australia
| | - Alicia Norman
- Centre for the Health Economy, Macquarie University Business School, Macquarie University, Macquarie, NSW, Australia
| | - Margaret Murphy
- Western Sydney Local Health District, New South Wales Health, Sydney, NSW, Australia
| | - Kylie Smith
- Emergency Care Institute, New South Wales Agency for Clinical Innovation, New South Wales Health, Sydney, NSW, Australia
| | - Donna Gillies
- Quality and Safeguards Commission, National Disability Insurance Scheme, Sydney, NSW, Australia
| | - Robyn Clay-Williams
- The Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Science, Macquarie University, Macquarie, NSW, Australia
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Kessler R, Hall J, Chipman AK, Hall MK, Amick A. Nurse-focused ultrasound-guided IV program improves core emergency department process measures. J Vasc Access 2024:11297298241230109. [PMID: 38372249 DOI: 10.1177/11297298241230109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2024] Open
Abstract
INTRODUCTION Ultrasound-guided peripheral IV catheter (USGIV) insertion is as an effective procedure to establish access in patients with difficult intravenous access (DIVA), a condition frequently encountered in the Emergency Department (ED). This study describes a DIVA quality improvement program focusing on rapid identification of DIVA patients and emergency nurse USGIV training and evaluates its impact on overall frequency of USGIV use and process measures related to quality of patient care. METHODS This is a retrospective cohort study of patients over 18 years of age, presenting to a single, tertiary care hospital between September 1, 2018 and September 30, 2020. Difference-in-difference analysis was used to compare ED process measures pre- and post-implementation of the DIVA Program, and multivariate logistic regression was used to identify associations between patient characteristics and difficult IV access. RESULTS The frequency of ED encounters associated with USGIV placement more than doubled post-implementation of the DIVA Program, rising from 606 to 1323. There were improved covariate-adjusted time estimates of core ED process measures for encounters associated with USGIV placement post-implementation, including decreases in time to CT with contrast from 4.8 h (95% CI = 4.4-5.2) to 4.1 h (95% CI = 3.8-4.4), pain medications from 2.4 h (95% CI = 2.1-2.6) to 1.8 h (95% CI = 1.6-2.0), IV antibiotics from 3.0 h (95% CI = 2.4-3.7) to 2.1 h (95% CI = 1.5-2.6), and ED length of stay from 6.4 h (95% CI = 6.2-6.6) to 6.0 h (95% CI = 5.9-6.2). CONCLUSION A nurse-focused quality improvement program focused on teaching and promoting USGIV as a modality for managing difficult IV access was associated with increases in USGIV placement and improvements in core process measures related to quality of patient care.
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Affiliation(s)
- Ross Kessler
- Department of Emergency Medicine, University of Washington, Seattle, WA, USA
| | - Jane Hall
- Department of Emergency Medicine, University of Washington, Seattle, WA, USA
| | - Anne K Chipman
- Department of Emergency Medicine, University of Washington, Seattle, WA, USA
| | | | - Ashley Amick
- Department of Emergency Medicine, University of Washington, Seattle, WA, USA
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Herring AA, Rosen AD, Samuels EA, Lin C, Speener M, Kaleekal J, Shoptaw SJ, Moulin AK, Campbell A, Anderson E, Kalmin MM. Emergency Department Access to Buprenorphine for Opioid Use Disorder. JAMA Netw Open 2024; 7:e2353771. [PMID: 38285444 PMCID: PMC10825722 DOI: 10.1001/jamanetworkopen.2023.53771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 12/05/2023] [Indexed: 01/30/2024] Open
Abstract
Importance Although substantial evidence supports buprenorphine for treatment of opioid use disorder (OUD) in controlled trials, prospective study of patient outcomes in clinical implementation of emergency department (ED) buprenorphine treatment is lacking. Objective To examine the association between buprenorphine treatment in the ED and follow-up engagement in OUD treatment 1 month later. Design, Setting, and Participants This multisite cohort study was conducted in 7 California EDs participating in a statewide implementation project to improve access to buprenorphine treatment. The study population included ED patients aged at least 18 years identified with OUD between April 1, 2021, and June 30, 2022. Data analysis was performed in October 2023. Exposure All participants were offered buprenorphine treatment for OUD (either in ED administration, prescription, or both), the uptake of which was examined as the exposure of interest. Main Outcomes and Measures The primary outcome was engagement in OUD treatment 30 days after the ED visit, determined by patient report or clinical documentation. The association of ED buprenorphine treatment with subsequent OUD treatment engagement was estimated using hierarchical generalized linear models. Results This analysis included 464 ED patients with OUD. Their median age was 36.0 (IQR, 29.0-38.7) years, and most were men (343 [73.9%]). With regard to race and ethnicity, 64 patients (13.8%) self-identified as non-Hispanic Black, 183 (39.4%) as Hispanic, and 185 as non-Hispanic White (39.9%). Most patients (396 [85.3%]) had Medicaid insurance, and more than half (262 [57.8%]) had unstable housing. Self-reported fentanyl use (242 [52.2%]) and a comorbid mental health condition (328 [71.5%]) were common. Interest in buprenorphine treatment was high: 398 patients (85.8%) received buprenorphine treatment; 269 (58.0%) were administered buprenorphine in the ED and 339 (73.1%) were prescribed buprenorphine. With regard to OUD treatment engagement at 30 days after the ED visit, 198 participants (49.7%) who received ED buprenorphine treatment remained engaged compared with 15 participants (22.7%) who did not receive ED buprenorphine treatment. An association of ED buprenorphine treatment with subsequent OUD treatment engagement at 30 days was observed (adjusted risk ratio, 1.97 [95% CI, 1.27-3.07]). Conclusions and Relevance The findings of this cohort study suggest that among patients with OUD presenting to EDs implementing low-threshold access to medications for OUD, buprenorphine treatment was associated with a substantially higher likelihood of follow-up treatment engagement 1 month later. Future research should investigate techniques to optimize both the uptake and effectiveness of buprenorphine initiation in low-threshold settings such as the ED.
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Affiliation(s)
- Andrew A. Herring
- Bridge, Public Health Institute, Oakland, California
- Department of Emergency Medicine, Highland General Hospital–Alameda Health System, Oakland, California
- Department of Emergency Medicine, University of California, San Francisco
| | - Allison D. Rosen
- Department of Family Medicine, David Geffen School of Medicine, University of California, Los Angeles
| | - Elizabeth A. Samuels
- Bridge, Public Health Institute, Oakland, California
- Department of Emergency Medicine, David Geffen School of Medicine, University of California, Los Angeles
| | - Chunqing Lin
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California, Los Angeles
| | | | - John Kaleekal
- Bridge, Public Health Institute, Oakland, California
| | - Steven J. Shoptaw
- Department of Family Medicine, David Geffen School of Medicine, University of California, Los Angeles
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California, Los Angeles
| | - Aimee K. Moulin
- Bridge, Public Health Institute, Oakland, California
- Department of Emergency Medicine, University of California, Davis, Sacramento, California
| | | | - Erik Anderson
- Bridge, Public Health Institute, Oakland, California
- Department of Emergency Medicine, Highland General Hospital–Alameda Health System, Oakland, California
- Department of Emergency Medicine, University of California, San Francisco
| | - Mariah M. Kalmin
- Department of Behavioral and Policy Sciences, RAND Corporation, Santa Monica, California
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