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Jack HE, Arif SA, Moore MA, Bhatraju EP, Thompson JL, Stewart MT, Hawk KF, Bartlett E. Peer support for patients with opioid use disorder in the emergency department: A narrative review. J Am Coll Emerg Physicians Open 2024; 5:e13253. [PMID: 39144727 PMCID: PMC11322658 DOI: 10.1002/emp2.13253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 07/12/2024] [Accepted: 07/22/2024] [Indexed: 08/16/2024] Open
Abstract
Faced with a growing opioid overdose crisis, emergency departments (EDs) are increasingly hiring peers-people with lived experiences of addiction and recovery-to work with patients in the ED who have opioid use disorders (OUDs) or who have experienced an opioid overdose. Despite a clear need for more support for patients with OUD and rapid expansion in grant funding for peer programs, there are limited data on how these programs affect clinical outcomes and how they are best implemented within the ED. In this narrative review, we synthesize the existing evidence on how to develop and implement peer programs for OUD in the ED setting. We describe the key activities peers can undertake in the ED, outline requirements of the peer role and best practices for peer supervision and hiring, detail how ED administrators have built financial and political support for peer programs, and summarize the limited evidence on clinical and care linkage outcomes of peer programs. We highlight key resources that ED clinicians and administrators can use to develop peer programs and key areas where additional research is needed.
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Affiliation(s)
- Helen E. Jack
- Division of General Internal MedicineDepartment of MedicineUniversity of Washington School of MedicineSeattleWashingtonUSA
| | - Shaheer A. Arif
- College of Arts and SciencesUniversity of WashingtonSeattleWashingtonUSA
| | - Michael A. Moore
- Division of General Internal MedicineDepartment of MedicineUniversity of Washington School of MedicineSeattleWashingtonUSA
| | - Elenore P. Bhatraju
- Division of General Internal MedicineDepartment of MedicineUniversity of Washington School of MedicineSeattleWashingtonUSA
| | - Jennifer L. Thompson
- Department of Emergency MedicineUniversity of New MexicoAlbuquerqueNew MexicoUSA
| | - Maureen T. Stewart
- Institute for Behavioral HealthThe Heller School for Social Policy and ManagementBrandeis UniversityWalthamMassachusettsUSA
| | - Kathryn F. Hawk
- Department of Emergency MedicineYale University School of MedicineNew HavenConnecticutUSA
| | - Emily Bartlett
- Department of Emergency MedicineUniversity of New MexicoAlbuquerqueNew MexicoUSA
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Garcia V, McCann L, Lauber E, Vaccaro C, Swauger M, Heckert DA. Opioid Overdoses and Take-Home Naloxone Interventions: Ethnographic Evidence for Individual-Level Barriers to Treatment of Opioid Use Disorders in Rural Appalachia. Subst Use Misuse 2024; 59:1313-1322. [PMID: 38635977 DOI: 10.1080/10826084.2024.2340986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/20/2024]
Abstract
Introduction: Research indicates that take-home naloxone (THN) is saving lives across rural Appalachia, but whether it also results in treatment for opioid use disorders (OUDs) remains unclear. This study involves a detailed qualitative analysis of interviews with 16 individuals who had overdosed on opioids 61 times to understand why a THN intervention does not routinely lead to OUD treatment. Methods: This study builds upon a one-year (2018) qualitative study on community responses to opioid overdose fatalities in four adjacent rural counties in Western Pennsylvania. Using a semi-structured interview guide, 16 individuals who had experienced one or more overdoses were interviewed. Using NVivo, the transcribed audio-recorded interviews were coded, and a thematic analysis of the coded text was conducted. Findings: Findings reveal that of the 29 overdoses that included a THN intervention, only eight resulted in treatment. The analysis derives five individual-level barriers to treatment: (1) opioid dependence, (2) denial/readiness, (3) opioid withdrawal fears, (4) incarceration concerns, and (5) stigma and shame. These barriers impeded treatment, even though all the interviewees knew of treatment programs, how to access them, and in some cases had undergone treatment previously. Discussion and Conclusion: findings indicate that there is evidence that the five barriers make entering treatment after a THN intervention challenging and seemingly insurmountable at times. Recommendations based on the findings include increasing efforts to reduce stigma of OUDs in the community, including self-stigma resulting from misusing opioids, increasing informational efforts about Good Samaritan Laws, and increasing familiarity with medication-assisted treatments for OUDS.
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Affiliation(s)
- Victor Garcia
- Research Scientist, Prevention Research Center, Berkeley, California, USA
| | - Lisa McCann
- Department of Sociology, Indiana University of Pennsylvania, Indiana, Pennsylvania, USA
| | - Erick Lauber
- Department of Communications Media, Indiana University of Pennsylvania, Indiana, Pennsylvania, USA
| | - Christian Vaccaro
- Department of Sociology Associate Director Mid Atlantic Research and, Training Institute Indiana University of Pennsylvania, Indiana, Pennsylvania, USA
| | - Melissa Swauger
- Nonprofit Management, Empowerment and Diversity Studies (new address), Slippery Rock University of Pennsylvania Slippery Rock, Pennsylvania, USA
| | - Daniel Alex Heckert
- Department of Sociology Director Mid Atlantic Research and Training Center, Indiana University of Pennsylvania, Indiana, Pennsylvania, USA
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Lin CH, Siao SF, Lin PY, Shelley M, Chi YC, Lee YH. Understanding Healthcare Providers' Care for Patients with Medications Treating Opioid Use Disorder in the Emergency Department: A Scoping Review. Subst Use Misuse 2024; 59:622-637. [PMID: 38115559 DOI: 10.1080/10826084.2023.2294964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2023]
Abstract
BACKGROUND There is limited research exploring the changing clinical practices among healthcare providers (HPs) care for patients with Emergency Department (ED)-initiated Medication for Opioid Use Disorder (MOUD). METHODS This scoping review followed the methodological framework of Arksey and O'Malley to map relevant evidence and synthesize the findings. We searched PubMed, EMBASE, CINAHL, Web of Science, and Scopus for related studies from inception through October 12, 2022. Following the application of inclusion and exclusion criteria, 16 studies were included. Subsequently, they were charted and analyzed thematically based on ecological systems theory. RESULTS The main determinants in the four ecological systems were generated as follows: (1) microsystem: willingness and attitude, professional competence, readiness, and preference; (2) mesosystem: ED clinical practices, departmental factors; (3) exosystem: multidisciplinary approaches, discharge planning, and (4) macrosystem: stigma, health insurance, policy. The findings have implications for HPs and researchers, as insufficient adoption, implementation, and retention of MOUD in the ED affect clinical practices. CONCLUSIONS Across the four ecological systems, ED-initiated MOUD is shaped by multifaceted determinants. The microsystem underscores pivotal patient-HP trust dynamics, while the mesosystem emphasizes interdepartmental synergies. Exosystemically, resource allocation and standardized training remain paramount. The macrosystem reveals profound effects of stigma, insurance disparities, and evolving policies on treatment access and efficacy. Addressing these interconnected barriers is crucial for optimizing patient outcomes in the context of MOUD.
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Affiliation(s)
- Chia-Hung Lin
- Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Nursing, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Shu-Fen Siao
- School of Nursing, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Pei-Ying Lin
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Mack Shelley
- Department of Political Science, Department of Statistics, Iowa State University, Ames, IA, USA
| | - Yu-Chi Chi
- Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yen-Han Lee
- Department of Health Sciences, College of Health Professions and Sciences, University of Central Florida, Orlando, FL, USA
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Kirk MR, Dawkins AD, Wei X, Ajumobi O, Lee LC, Oman R, Woodard S, Wagner KD. What makes a peer? Characteristics of certified peer recovery support specialists in an emergency department-based intervention. PLoS One 2023; 18:e0289920. [PMID: 38060503 PMCID: PMC10703250 DOI: 10.1371/journal.pone.0289920] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 07/28/2023] [Indexed: 12/18/2023] Open
Abstract
Providing brief interventions by certified peer recovery support specialists (CPRSS) in the emergency department (ED) following a drug related visit is a promising method of service engagement and has garnered national attention. This study examines CPRSS's perceptions of the qualities that enable them to deliver interventions in the ED. We conducted qualitative interviews with 14 CPRSSs working in EDs. Interview topics included how the participants became involved with CPRSS work, experiences working in the ED, how the ED differs from other settings, and what interactions with patients look like. Interviews were digitally recorded, transcribed, and analyzed for emerging categories. Three categories were identified relating to CPRSS work: (1) how they approach peer work, (2) inherent qualities required to do the work, regardless of the setting, and (3) context-specific skills required to do the work in the ED. When describing their approach to this work, participants talked about CPRSS work as their life calling and their passion. Participants also identified certain qualities that all CPRSS workers possess, regardless of the setting, including the ability to build rapport, strong listening skills, and a shared lived experience. Lastly, participants identified how specific hard and soft skills help them to navigate organizational and structural challenges in the ED. The unique conditions of the ED and the required qualities of a CPRSS should be considered when implementing an ED-based intervention.
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Affiliation(s)
- Mia R. Kirk
- School of Public Health, University of Nevada, Reno, Reno, Nevada, United States of America
| | - Ashley D. Dawkins
- School of Public Health, University of Nevada, Reno, Reno, Nevada, United States of America
| | - Xing Wei
- School of Public Health, University of Nevada, Reno, Reno, Nevada, United States of America
| | - Olufemi Ajumobi
- School of Public Health, University of Nevada, Reno, Reno, Nevada, United States of America
| | - Lisa C. Lee
- Roots to Wings Consulting, LLC, Reno, Nevada, United States of America
| | - Roy Oman
- School of Public Health, University of Nevada, Reno, Reno, Nevada, United States of America
| | - Stephanie Woodard
- Division of Public and Behavioral Health, Bureau of Behavioral Health, Wellness and Prevention, State of Nevada, Carson City, Nevada, United States of America
| | - Karla D. Wagner
- School of Public Health, University of Nevada, Reno, Reno, Nevada, United States of America
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Lowenstein M, Perrone J, McFadden R, Xiong RA, Meisel ZF, O'Donnell N, Abdel-Rahman D, Moon J, Mitra N, Delgado MK. Impact of Universal Screening and Automated Clinical Decision Support for the Treatment of Opioid Use Disorder in Emergency Departments: A Difference-in-Differences Analysis. Ann Emerg Med 2023; 82:131-144. [PMID: 37318434 PMCID: PMC11019868 DOI: 10.1016/j.annemergmed.2023.03.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 03/23/2023] [Accepted: 03/28/2023] [Indexed: 06/16/2023]
Abstract
STUDY OBJECTIVE Emergency department (ED)-initiated buprenorphine improves outcomes in patients with opioid use disorder; however, adoption varies widely. To reduce variability, we implemented a nurse-driven triage screening question in the electronic health record to identify patients with opioid use disorder, followed by targeted electronic health record prompts to measure withdrawal and guide next steps in management, including initiation of treatment. Our objective was to assess the impact of screening implementation in 3 urban, academic EDs. METHODS We conducted a quasiexperimental study of opioid use disorder-related ED visits using electronic health record data from January 2020 to June 2022. The triage protocol was implemented in 3 EDs between March and July 2021, and 2 other EDs in the health system served as controls. We evaluated changes in treatment measures over time and used a difference-in-differences analysis to compare outcomes in the 3 intervention EDs with those in the 2 controls. RESULTS There were 2,462 visits in the intervention hospitals (1,258 in the preperiod and 1,204 in the postperiod) and 731 in the control hospitals (459 in the preperiod and 272 in the postperiod). Patient characteristics within the intervention and control EDs were similar across the time periods. Compared with the control hospitals, the triage protocol was associated with a 17% greater increase in withdrawal assessment, using the Clinical Opioid Withdrawal Scale (COWS) (95% CI 7 to 27). Buprenorphine prescriptions at discharge also increased by 5% (95% CI 0% to 10%), and naloxone prescriptions increased by 12% points (95% CI 1% to 22%) in the intervention EDs relative to controls. CONCLUSION An ED triage screening and treatment protocol led to increased assessment and treatment of opioid use disorder. Protocols designed to make screening and treatment the default practice have promise in increasing the implementation of evidence-based treatment ED opioid use disorder care.
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Affiliation(s)
- Margaret Lowenstein
- Division of General Internal Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Center for Addiction Medicine and Policy, University of Pennsylvania, Philadelphia, PA.
| | - Jeanmarie Perrone
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Center for Addiction Medicine and Policy, University of Pennsylvania, Philadelphia, PA
| | - Rachel McFadden
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Center for Addiction Medicine and Policy, University of Pennsylvania, Philadelphia, PA
| | - Ruiying Aria Xiong
- Division of General Internal Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Penn Medicine Nudge Unit, University of Pennsylvania Health System, Philadelphia, PA
| | - Zachary F Meisel
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Nicole O'Donnell
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Center for Addiction Medicine and Policy, University of Pennsylvania, Philadelphia, PA
| | - Dina Abdel-Rahman
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Penn Medicine Nudge Unit, University of Pennsylvania Health System, Philadelphia, PA
| | - Jeffrey Moon
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Nandita Mitra
- Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Mucio Kit Delgado
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Penn Medicine Nudge Unit, University of Pennsylvania Health System, Philadelphia, PA
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Ray B, Christian K, Bailey T, Alton M, Proctor A, Haggerty J, Lowder E, Aalsma MC. Antecedents of fatal overdose in an adult cohort identified through administrative record linkage in Indiana, 2015-2022. Drug Alcohol Depend 2023; 247:109891. [PMID: 37120921 DOI: 10.1016/j.drugalcdep.2023.109891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 04/17/2023] [Accepted: 04/19/2023] [Indexed: 05/02/2023]
Abstract
BACKGROUND The United States continues to experience unprecedented rates of overdose mortality and need to identify effective policies or practices that can be implemented. This study aims to measure the prevalence, frequency, timing, and rate of touchpoints that occurred prior to a fatal overdose where communities might intervene. METHODS In collaboration with Indiana state government, we conducted record-linkage of statewide administrative datasets to vital records (January 1, 2015, through August 26, 2022) to identify touchpoints (jail booking, prison release, prescription medication dispensation, emergency department visits, and emergency medical services). We examined touchpoints within 12-months prior to a fatal overdose among an adult cohort and explored variation over time and by demographic characteristics. RESULTS Over the 92-month study period there were 13,882 overdose deaths (89.3% accidental poisonings, X40-X44) in our adult cohort that were record-linked to multiple administrative datasets and revealed nearly two-thirds (64.7%; n=8980) experienced an emergency department visit, the most prevalent touchpoint followed by prescription medication dispensation, emergency medical services responses, jail booking, and prison release. However, with approximately 1 out of every 100 returning citizens dying from drug overdose within 12-months of release, prison release had the highest touchpoint rate followed by emergency medical services responses, jail booking, emergency department visits, and prescription medication dispensation. CONCLUSION Record-linking administrative data from routine practice to vital records from overdose mortality is a viable means of identifying where resources should be situated to reduce fatal overdose, with potential to evaluate the effectiveness of overdose prevention efforts.
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Affiliation(s)
- Bradley Ray
- RTI International, 3040 Cornwallis Road, Research Triangle Park, NC27709, United States.
| | - Kaitlyn Christian
- Indiana Management Performance Hub, 100 North Senate Avenue, Room N855, Indianapolis, IN46204, United States
| | - Timothy Bailey
- Indiana Management Performance Hub, 100 North Senate Avenue, Room N855, Indianapolis, IN46204, United States
| | - Madison Alton
- Indiana Division of Mental Health and Addiction, 402 West Washington Street W353, Indiana, IN46204, United States
| | - Alison Proctor
- RTI International, 3040 Cornwallis Road, Research Triangle Park, NC27709, United States
| | - John Haggerty
- RTI International, 3040 Cornwallis Road, Research Triangle Park, NC27709, United States
| | - Evan Lowder
- Department of Criminology, Law and Society, George Mason University, 4400 University Drive, 4F4, Fairfax, VA22030, United States
| | - Matthew C Aalsma
- Department of Pediatrics, Indiana University School of Medicine, 340 W. 10th StreetIndianapolisIN46202, United States
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Trope LA, Stemmle M, Chang A, Bashiri N, Bazazi AR, Lightfoot M, Congdon JL. A Novel Inpatient Buprenorphine Induction Program for Adolescents With Opioid Use Disorder. Hosp Pediatr 2023; 13:e23-e28. [PMID: 36683456 DOI: 10.1542/hpeds.2022-006864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Morbidity and mortality from nonprescribed opioid use and opioid use disorder (OUD) in adolescents have risen dramatically. Medication for opioid use disorder (MOUD) with buprenorphine reduces nonprescribed opioid use and prevents overdoses, though <5% of adolescents with OUD have timely access, partly because of barriers associated with buprenorphine induction. Induction in an inpatient pediatric setting has the potential to address such barriers and improve adolescent MOUD access. METHODS We developed and implemented a protocol for inpatient buprenorphine induction and linkage to MOUD care within a safety-net health system. After 1 year, we conducted descriptive analysis of participant characteristics, rates of induction completion and treatment linkage, and adverse events. We analyzed field notes from multidisciplinary huddles to identify implementation facilitators and barriers. RESULTS During May 2021 to July 2022, we completed 46 admissions for 36 patients aged 12 to 21 years. All used fentanyl and no other opioids. Forty of 46 (87%) admissions resulted in completed induction, and 3 additional patients never developed withdrawal symptoms and were discharged with maintenance buprenorphine. Linkage to ongoing treatment occurred within 2 weeks for 31 of 43 (72%) admissions for which buprenorphine was started. We identified facilitators and barriers to program implementation and maintenance. CONCLUSION These results provide promising preliminary evidence of the feasibility of inpatient buprenorphine induction for adolescents with OUD. Given the public health urgency and severe shortage of adolescent access to MOUD, these results prompt consideration of broader clinical implementation and research to facilitate rapid expansion of access to evidence-based OUD care.
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Affiliation(s)
| | | | - Annie Chang
- Family Medicine, Valley Homeless Healthcare Program
| | - Nasrin Bashiri
- Addiction Medicine, Santa Clara Valley Medical Center, San Jose, California
| | | | - Marguerita Lightfoot
- School of Public Health, Oregon Health and Science University and Portland State University, Portland, Oregon
| | - Jayme L Congdon
- Pediatrics, University of California, San Francisco, California
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Thomas CP, Stewart MT, Tschampl C, Sennaar K, Schwartz D, Dey J. Emergency department interventions for opioid use disorder: A synthesis of emerging models. J Subst Abuse Treat 2022; 141:108837. [PMID: 35841743 DOI: 10.1016/j.jsat.2022.108837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 05/26/2022] [Accepted: 07/04/2022] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Opioid overdose deaths are increasing, and improving access to evidence-based treatment is necessary. Emergency department (ED) initiation of treatment for opioid use disorder (OUD) via medications and referral to treatment is one approach that leverages a critical health care entry point for individuals with OUD. Efforts to engage patients in treatment through the ED are growing, but systematic analysis of program features as implemented and challenges across different models remains limited. Lessons from early adopter programs may benefit clinicians and others looking to offer ED-initiated treatment for OUD. METHODS We conducted case studies of five ED-based efforts to address OUD across the United States, selected for diversity in structure, approach, and geography. We conducted telephone interviews with 37 individuals (ED physicians, ED nurses, navigators, hospital administrators, community providers, and state policymakers) affiliated with the five programs. Interviews were transcribed, coded, and analyzed using a framework analysis approach, identifying relevant lessons for replication. RESULTS These five programs (an academic medical center, two large urban hospitals, a rural community hospital, and a community-based program) successfully implemented ED-initiated MOUD. Often a champion with knowledge of OUD treatment and a reliable connection with outpatient treatment began the program. The approach to patient identification varied from universal screening to relying on patient self-identification. Substance use treatment navigators provide crucial services but can be difficult to pay for within current reimbursement frameworks. Barriers to implementation include lack of knowledge about treatment options and effectiveness, stigma, community treatment capacity limits, and health insurance and reimbursement policies. Facilitators of success include taking a patient-centered, low-barrier approach, having a passionate champion, a strong structure with health system support, and a relationship with community partners. Metrics for success vary across programs. Some programs are expanding to include treating the use of other substances such as alcohol and stimulants. CONCLUSION ED-initiated MOUD is feasible across different settings. Research and real world efforts need to promote programs that include OUD treatment as standard in ED treatment.
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Affiliation(s)
- Cindy Parks Thomas
- Schneider Institutes for Health Policy, The Heller School for Social Policy and Management, Brandeis University, Waltham, MA, United States of America.
| | - Maureen T Stewart
- Institute for Behavioral Health, Schneider Institutes for Health Policy, The Heller School for Social Policy and Management, Brandeis University, Waltham, MA, United States of America.
| | - Cynthia Tschampl
- Institute for Behavioral Health, Schneider Institutes for Health Policy, The Heller School for Social Policy and Management, Brandeis University, Waltham, MA, United States of America.
| | - Kumba Sennaar
- Schneider Institutes for Health Policy, The Heller School for Social Policy and Management, Brandeis University, Waltham, MA, United States of America.
| | - Daniel Schwartz
- US Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation (ASPE), 200 Independence Avenue, SW Washington, DC 20201, Rm 415F, United States of America.
| | - Judith Dey
- US Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation (ASPE), 200 Independence Avenue, SW Washington, DC 20201, Rm 415F, United States of America.
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