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Light AE, Green TC, Freeman PR, Zadeh PS, Burns AL, Hill LG. Relationships Between Stigma, Risk Tolerance, and Buprenorphine Dispensing Intentions Among Community-Based Pharmacists: Results From a National Sample. SUBSTANCE USE & ADDICTION JOURNAL 2024; 45:211-221. [PMID: 38258805 DOI: 10.1177/29767342231215178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
BACKGROUND Concerns have been raised that pharmacists sometimes act as barriers to patients with opioid use disorder (OUD) accessing buprenorphine treatment. The present research explores how community pharmacists' endorsement (vs non-endorsement) of stigmatizing beliefs about patients taking buprenorphine relate to intentions, comfort, and decisions regarding dispensing buprenorphine for OUD. In addition, we assessed attitudes toward risk in pharmacy practice as a novel correlate of dispensing intentions and decisions. METHODS A sample of 207 active community-based pharmacists practicing in the United States responded to survey items measuring stigma, risk tolerance, and intentions to dispense buprenorphine. The survey included 2 vignettes in which patients presented to the pharmacy with a prescription for buprenorphine, and respondents rated their comfort with dispensing and decisions regarding dispensing in the vignette. RESULTS Results suggest that both stigma toward patients taking buprenorphine to treat OUD and tolerance for risk in pharmacy settings are related to differences in pharmacists' intentions to and willingness to dispense buprenorphine for OUD. CONCLUSIONS Findings support the need for interventions to reduce stigma associated with buprenorphine use among pharmacists and suggest that risk tolerance is an important determinant of pharmacists' behavior that merits further study.
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Affiliation(s)
| | | | | | | | - Anne L Burns
- American Pharmacists Association, Washington, DC, USA
| | - Lucas G Hill
- The University of Texas at Austin, Austin, TX, USA
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Smulowitz PB, Burke RC, Ostrovsky D, Novack V, Isbell L, Kan V, Landon BE. Clinician Risk Tolerance and Rates of Admission From the Emergency Department. JAMA Netw Open 2024; 7:e2356189. [PMID: 38363570 PMCID: PMC10873771 DOI: 10.1001/jamanetworkopen.2023.56189] [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: 08/14/2023] [Accepted: 12/21/2023] [Indexed: 02/17/2024] Open
Abstract
Importance Much remains unknown about the extent of and factors that influence clinician-level variation in rates of admission from the emergency department (ED). In particular, emergency clinician risk tolerance is a potentially important attribute, but it is not well defined in terms of its association with the decision to admit. Objective To further characterize this variation in rates of admission from the ED and to determine whether clinician risk attitudes are associated with the propensity to admit. Design, Setting, and Participants In this observational cohort study, data were analyzed from the Massachusetts All Payer Claims Database to identify all ED visits from October 2015 through December 2017 with any form of commercial insurance or Medicaid. ED visits were then linked to treating clinicians and their risk tolerance scores obtained in a separate statewide survey to examine the association between risk tolerance and the decision to admit. Statistical analysis was performed from 2022 to 2023. Main Outcomes and Measures The ratio between observed and projected admission rates was computed, controlling for hospital, and then plotted against the projected admission rates to find the extent of variation. Pearson correlation coefficients were then used to examine the association between the mean projected rate of admission and the difference between actual and projected rates of admission. The consistency of clinician admission practices across a range of the most common conditions resulting in admission were then assessed to understand whether admission decisions were consistent across different conditions. Finally, an assessment was made as to whether the extent of deviation from the expected admission rates at an individual level was associated with clinician risk tolerance. Results The study sample included 392 676 ED visits seen by 691 emergency clinicians. Among patients seen for ED visits, 221 077 (56.3%) were female, and 236 783 (60.3%) were 45 years of age or older; 178 890 visits (46.5%) were for patients insured by Medicaid, 96 947 (25.2%) were for those with commercial insurance, 71 171 (18.5%) were Medicare Part B or Medicare Advantage, and the remaining 37 702 (9.8%) were other insurance category. Of the 691 clinicians, 429 (62.6%) were male; mean (SD) age was 46.5 (9.8) years; and 72 (10.4%) were Asian, 13 (1.9%) were Black, 577 (83.5%) were White, and 29 (4.2%) were other race. Admission rates across the clinicians included ranged from 36.3% at the 25th percentile to 48.0% at the 75th percentile (median, 42.1%). Overall, there was substantial variation in admission rates across clinicians; physicians were just as likely to overadmit or underadmit across the range of projected rates of admission (Pearson correlation coefficient, 0.046 [P = .23]). There also was weak consistency in admission rates across the most common clinical conditions, with intraclass correlations ranging from 0.09 (95% CI, 0.02-0.17) for genitourinary/syncope to 0.48 (95% CI, 0.42-0.53) for cardiac/syncope. Greater clinician risk tolerance (as measured by the Risk Tolerance Scale) was associated with a statistically significant tendency to admit less than the projected admission rate (coefficient, -0.09 [P = .04]). The other scales studied revealed no significant associations. Conclusions and Relevance In this cohort study of ED visits from Massachusetts, there was statistically significant variation between ED clinicians in admission rates and little consistency in admission tendencies across different conditions. Admission tendencies were minimally associated with clinician innate risk tolerance as assessed by this study's measures; further research relying on a broad range of measures of risk tolerance is needed to better understand the role of clinician attitudes toward risk in explaining practice patterns and to identify additional factors that may be associated with variation at the clinician level.
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Affiliation(s)
- Peter B. Smulowitz
- Department of Emergency Medicine, University of Massachusetts Medical School, Worcester
- Milford Regional Medical Center, Milford, Massachusetts
| | - Ryan C. Burke
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Daniel Ostrovsky
- Soroka University Medical Center, Ben-Gurion University of the Negev, Be’er-Sheva, Israel
| | - Victor Novack
- Soroka University Medical Center, Ben-Gurion University of the Negev, Be’er-Sheva, Israel
| | - Linda Isbell
- Department of Psychological and Brain Sciences, University of Massachusetts, Amherst
| | - Vincent Kan
- Department of Emergency Medicine, University of Massachusetts Medical School, Worcester
| | - Bruce E. Landon
- Department of Health Care Policy, Harvard Medical School and Division of General Internal Medicine, Beth Israel Deaconess Medical Center, Boston
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Impact of coronary risk scores on disposition decision in emergency patients with chest pain. Am J Emerg Med 2021; 48:165-169. [PMID: 33957340 DOI: 10.1016/j.ajem.2021.04.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 04/04/2021] [Accepted: 04/10/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Coronary risk scores (CRS) including History, Electrocardiogram, Age, Risk Factors, Troponin (HEART) score and Emergency Department Assessment of Chest pain Score (EDACS) can help identify patients at low risk of major adverse cardiac events. In the emergency department (ED), there are wide variations in hospital admission rates among patients with chest pain. OBJECTIVE This study aimed to evaluate the impact of CRS on the disposition of patients with symptoms suggestive of acute coronary syndrome in the ED. METHODS This retrospective cohort study included 3660 adult patients who presented to the ED with chest pain between January and July in 2019. Study inclusion criteria were age > 18 years and a primary position International Statistical Classification of Diseases and Related Health Problems-10th revision coded diagnosis of angina pectoris (I20.0-I20.9) or chronic ischemic heart disease (I25.0-I25.9) by the treating ED physician. If the treating ED physician completed the electronic structured variables for CRS calculation to assist disposition planning, then the patient would be classified as the CRS group; otherwise, the patient was included in the control group. RESULTS Among the 2676 patients, 746 were classified into the CRS group, whereas the other 1930 were classified into the control group. There was no significant difference in sex, age, initial vital signs, and ED length of stay between the two groups. The coronary risk factors were similar between the two groups, except for a higher incidence of smokers in the CRS group (19.6% vs. 16.1%, p = 0.031). Compared with the control group, significantly more patients were discharged (70.1% vs. 64.6%) directly from the ED, while fewer patients who were hospitalized (25.9% vs. 29.7%) or against-advise discharge (AAD) (2.6% vs. 4.0%) in the CRS group. Major adverse cardiac events and mortality at 60 days between the two groups were not significantly different. CONCLUSIONS A higher ED discharge rate of the group using CRS may indicate that ED physicians have more confidence in discharging low-risk patients based on CRS.
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Adams AJ, O'Hara NN, Abzug JM, Aoyama JT, Ganley TJ, Carey JL, Cruz AI, Ellis HB, Fabricant PD, Green DW, Heyworth BE, Janicki JA, Kocher MS, Lawrence JTR, Lee RJ, McKay SD, Mistovich RJ, Patel NM, Polousky JD, Rhodes JT, Sachleben BC, Sargent MC, Schmale GA, Shea KG, Yen YM. Pediatric Type II Tibial Spine Fractures: Addressing the Treatment Controversy With a Mixed-Effects Model. Orthop J Sports Med 2019; 7:2325967119866162. [PMID: 31489334 PMCID: PMC6713965 DOI: 10.1177/2325967119866162] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background: Tibial spine fractures, although relatively rare, account for a substantial
proportion of pediatric knee injuries with effusions and can have
significant complications. Meyers and McKeever type II fractures are
displaced anteriorly with an intact posterior hinge. Whether this subtype of
pediatric tibial spine fracture should be treated operatively or
nonoperatively remains controversial. Surgical delay is associated with an
increased risk of arthrofibrosis; thus, prompt treatment decision making is
imperative. Purpose: To assess for variability among pediatric orthopaedic surgeons when treating
pediatric type II tibial spine fractures. Study Design: Cross-sectional study. Methods: A discrete choice experiment was conducted to determine the patient and
injury attributes that influence the management choice. A convenience sample
of 20 pediatric orthopaedic surgeons reviewed 40 case vignettes, including
physis-blinded radiographs displaying displaced fractures and a description
of the patient’s sex, age, mechanism of injury, and predominant sport.
Surgeons were asked whether they would treat the fracture operatively or
nonoperatively. A mixed-effects model was then used to determine the patient
attributes most likely to influence the surgeon’s decision, as well as
surgeon training background, years in practice, and risk-taking
behavior. Results: The majority of respondents selected operative treatment for 85% of the
presented cases. The degree of fracture displacement was the only attribute
significantly associated with treatment choice (P <
.001). Surgeons were 28% more likely to treat the fracture operatively with
each additional millimeter of displacement of fracture fragment. Over 64% of
surgeons chose to treat operatively when the fracture fragment was displaced
by ≥3.5 mm. Significant variation in surgeon’s propensity for operative
treatment of this fracture was observed (P = .01). Surgeon
training, years in practice, and risk-taking scores were not associated with
the respondent’s preference for surgical treatment. Conclusion: There was substantial variation among pediatric orthopaedic surgeons when
treating type II tibial spine fractures. The decision to operate was based
on the degree of fracture displacement. Identifying current treatment
preferences among surgeons given different patient factors can highlight
current variation in practice patterns and direct efforts toward promoting
the most optimal treatment strategies for controversial type II tibial spine
fractures.
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Affiliation(s)
- Alexander J Adams
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Nathan N O'Hara
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Joshua M Abzug
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Julien T Aoyama
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | - Theodore J Ganley
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - James L Carey
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Aristides I Cruz
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Henry B Ellis
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Peter D Fabricant
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Daniel W Green
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Benton E Heyworth
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Joseph A Janicki
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Mininder S Kocher
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - John T R Lawrence
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - R Jay Lee
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Scott D McKay
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - R Justin Mistovich
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Neeraj M Patel
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - John D Polousky
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jason T Rhodes
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Brant C Sachleben
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - M Catherine Sargent
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Gregory A Schmale
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Kevin G Shea
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Yi-Meng Yen
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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