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Becker SJ, Janssen T, Shiller H, DiBartolo E, Fan Y, Souza T, Kelly LM, Helseth SA. Parent SMART: Effects of residential treatment and an adjunctive parenting intervention on behavioral health services utilization. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024:209399. [PMID: 38762125 DOI: 10.1016/j.josat.2024.209399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 04/13/2024] [Accepted: 05/06/2024] [Indexed: 05/20/2024]
Abstract
INTRODUCTION Scant research has examined the impact of residential treatment on adolescent behavioral healthcare utilization post-discharge, even though behavioral healthcare utilization is major driver of healthcare costs. In the primary analyses of a pilot randomized trial, Parent SMART - a technology-assisted intervention for parents of adolescents in residential treatment - was found to improve parental monitoring and parent-adolescent communication, reduce adolescent drinking, and reduce adolescent school-related problems, relative to residential treatment as usual (TAU). The goal of this secondary analysis of the pilot randomized trial was to assess the effects of residential treatment and the adjunctive Parent SMART intervention on both the amount and type of subsequent behavioral healthcare utilization. METHOD The study randomized sixty-one parent-adolescent dyads to residential TAU (n = 31) or residential TAU plus Parent SMART (n = 30). Of the 61 dyads, 37 were recruited from a short-term residential facility and 24 were recruited from a long-term facility. Adolescents completed a structured clinical interview and self-reported their behavioral health-related visits to the emergency department, nights in residential/inpatient, and outpatient visits over the past 90 days, at baseline, 12-, and 24-weeks post-discharge. Generalized linear mixed models (GLMMs) examined both linear and non-linear (pre- to post- residential treatment) trends, pooled, and stratified by residential facility to examine behavioral health service utilization. RESULTS Both the linear and pre-post GLMMs revealed that behavioral health-related emergency department visits and residential/inpatient nights decreased across both residential facilities. GLMMs estimating change from the pre- to post period indicated that outpatient visits increased across both facilities. There were no significant effects of the Parent SMART adjunctive intervention in GLMMs, though bivariate tests and the direction of effects signaled that Parent SMART was associated with more nights of residential/inpatient utilization. CONCLUSION Residential substance use treatment may reduce adolescents' subsequent utilization of costly behavioral healthcare services such as emergency department visits and residential/inpatient nights, while increasing utilization of outpatient services. Parent SMART was not associated with significant changes in behavioral healthcare utilization, but the pattern of results was consistent with prior literature suggesting that stronger parenting skills are associated with greater utilization of non-emergency services.
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Affiliation(s)
- Sara J Becker
- Center for Dissemination and Implementation Science, Northwestern University Feinberg School of Medicine, United States of America.
| | - Tim Janssen
- Department of Behavioral and Social Sciences, Brown University School of Public Health, United States of America
| | - Hannah Shiller
- Center for Dissemination and Implementation Science, Northwestern University Feinberg School of Medicine, United States of America
| | - Emily DiBartolo
- Center for Dissemination and Implementation Science, Northwestern University Feinberg School of Medicine, United States of America
| | - Yiqing Fan
- Center for Dissemination and Implementation Science, Northwestern University Feinberg School of Medicine, United States of America
| | - Timothy Souza
- Department of Behavioral and Social Sciences, Brown University School of Public Health, United States of America
| | - Lourah M Kelly
- Department of Psychiatry, Implementation Science and Practice Advances Research Center, University of Massachusetts Chan School of Medicine, United States of America
| | - Sarah A Helseth
- Center for Dissemination and Implementation Science, Northwestern University Feinberg School of Medicine, United States of America
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Nordeck CD, Kelly SM, Schwartz RP, Mitchell SG, Welsh C, O'Grady KE, Gryczynski J. Hospital admissions among patients with Comorbid Substance Use disorders: a secondary analysis of predictors from the NavSTAR Trial. Addict Sci Clin Pract 2024; 19:33. [PMID: 38678216 PMCID: PMC11056040 DOI: 10.1186/s13722-024-00463-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 04/09/2024] [Indexed: 04/29/2024] Open
Abstract
BACKGROUND Individuals with substance use disorders (SUDs) frequently use acute hospital services. The Navigation Services to Avoid Rehospitalization (NavSTAR) trial found that a patient navigation intervention for hospitalized patients with comorbid SUDs reduced subsequent inpatient admissions compared to treatment-as-usual (TAU). METHODS This secondary analysis extends previous findings from the NavSTAR trial by examining whether selected patient characteristics independently predicted hospital service utilization and moderated the effect of the NavSTAR intervention. Participants were 400 medical/surgical hospital patients with comorbid SUDs. We analyzed 30- and 90-day inpatient readmissions (one or more readmissions) and cumulative incidence of inpatient admissions through 12 months using multivariable logistic and negative binomial regression, respectively. RESULTS Consistent with primary findings and controlling for patient factors, NavSTAR participants were less likely than TAU participants to be readmitted within 30 (P = 0.001) and 90 (P = 0.03) days and had fewer total readmissions over 12 months (P = 0.008). Hospitalization in the previous year (P < 0.001) was associated with cumulative readmissions over 12 months, whereas Medicaid insurance (P = 0.03) and index diagnoses of infection (P = 0.001) and injuries, poisonings, or procedural complications (P = 0.004) were associated with fewer readmissions. None of the selected covariates moderated the effect of the NavSTAR intervention. CONCLUSIONS Previous findings showed that patient navigation could reduce repeat hospital admissions among patients with comorbid SUDs. Several patient factors were independently associated with readmission. Future research should investigate risk factors for hospital readmission among patients with comorbid SUDs to optimize interventions. TRIAL REGISTRATION NIH ClinicalTrials.gov NCT02599818, Registered November 9, 2015 https://classic. CLINICALTRIALS gov/ct2/show/NCT02599818 .
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Affiliation(s)
- Courtney D Nordeck
- Friends Research Institute, 1040 Park Avenue #103, Baltimore, MD, USA, 21201.
| | - Sharon M Kelly
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Robert P Schwartz
- Friends Research Institute, 1040 Park Avenue #103, Baltimore, MD, USA, 21201
| | - Shannon G Mitchell
- Friends Research Institute, 1040 Park Avenue #103, Baltimore, MD, USA, 21201
| | | | | | - Jan Gryczynski
- Friends Research Institute, 1040 Park Avenue #103, Baltimore, MD, USA, 21201
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Evans SK, Ober AJ, Korn AR, Peltz A, Friedmann PD, Page K, Murray-Krezan C, Huerta S, Ryzewicz SJ, Tarhuni L, Nuckols TK, E Watkins K, Danovitch I. Contextual barriers and enablers to establishing an addiction-focused consultation team for hospitalized adults with opioid use disorder. Addict Sci Clin Pract 2024; 19:31. [PMID: 38671482 PMCID: PMC11046820 DOI: 10.1186/s13722-024-00461-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 04/02/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Hospitalization presents an opportunity to begin people with opioid use disorder (OUD) on medications for opioid use disorder (MOUD) and link them to care after discharge; regrettably, people admitted to the hospital with an underlying OUD typically do not receive MOUD and are not connected with subsequent treatment for their condition. To address this gap, we launched a multi-site randomized controlled trial to test the effectiveness of a hospital-based addiction consultation team (the Substance Use Treatment and Recovery Team (START)) consisting of an addiction medicine specialist and care manager team that provide collaborative care and a specified intervention to people with OUD during the inpatient stay. Successful implementation of new practices can be impacted by organizational context, though no previous studies have examined context prior to implementation of addiction consultation services (ACS). This study assessed pre-implementation context for implementing a specialized ACS and tailoring it accordingly. METHODS We conducted semi-structured interviews with hospital administrators, physicians, physician assistants, nurses, and social workers at the three study sites between April and August 2021 before the launch of the pragmatic trial. Using an analytical framework based on the Consolidated Framework for Implementation Research, we completed a thematic analysis of interview data to understand potential barriers or enablers and perceptions about acceptability and feasibility. RESULTS We interviewed 28 participants across three sites. The following themes emerged across sites: (1) START is an urgently needed model for people with OUD; (2) Intervention adaptations are recommended to meet local and cultural needs; (3) Linking people with OUD to community clinicians is a highly needed component of START; (4) It is important to engage stakeholders across departments and roles throughout implementation. Across sites, participants generally saw a need for change from usual care to support people with OUD, and thought the START was acceptable and feasible to implement. Differences among sites included tailoring the START to support the needs of varying patient populations and different perceptions of the prevalence of OUD. CONCLUSIONS Hospitals planning to implement an ACS in the inpatient setting may wish to engage in a systematic pre-implementation contextual assessment using a similar framework to understand and address potential barriers and contextual factors that may impact implementation. Pre-implementation work can help ensure the ACS and other new practices fit within each unique hospital context.
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Affiliation(s)
- Sandra K Evans
- RAND Corporation, 1776 Main Street, 90407‑2138, Santa Monica, CA, P.O. Box 2138, USA.
| | - Allison J Ober
- RAND Corporation, 1776 Main Street, 90407‑2138, Santa Monica, CA, P.O. Box 2138, USA
| | - Ariella R Korn
- RAND Corporation, 1776 Main Street, 90407‑2138, Santa Monica, CA, P.O. Box 2138, USA
| | - Alex Peltz
- RAND Corporation, 1776 Main Street, 90407‑2138, Santa Monica, CA, P.O. Box 2138, USA
| | - Peter D Friedmann
- Department of Medicine, University of Massachusetts Chan Medical School-Baystate and Baystate Health, 3601 Main Street, 3rd Floor, 01107, Springfield, MA, USA
| | - Kimberly Page
- University of New Mexico Health Sciences Center, 1 University, MSC10 5550, 87133, Albuquerque, NM, USA
| | - Cristina Murray-Krezan
- Departement of Medicine, University of Pittsburgh School of Medicine, 200 Meyran Ave, Suite 300, 15213, Pittsburgh, PA, USA
| | - Sergio Huerta
- University of New Mexico Health Sciences Center, 1 University, MSC10 5550, 87133, Albuquerque, NM, USA
| | - Stephen J Ryzewicz
- Department of Medicine, University of Massachusetts Chan Medical School-Baystate and Baystate Health, 3601 Main Street, 3rd Floor, 01107, Springfield, MA, USA
| | - Lina Tarhuni
- University of New Mexico Health Sciences Center, 1 University, MSC10 5550, 87133, Albuquerque, NM, USA
| | - Teryl K Nuckols
- RAND Corporation, 1776 Main Street, 90407‑2138, Santa Monica, CA, P.O. Box 2138, USA
- Cedars-Sinai Medical Center, 8700 Beverly Boulevard, 90048, West Hollywood, CA, USA
| | - Katherine E Watkins
- RAND Corporation, 1776 Main Street, 90407‑2138, Santa Monica, CA, P.O. Box 2138, USA
| | - Itai Danovitch
- Cedars-Sinai Medical Center, 8700 Beverly Boulevard, 90048, West Hollywood, CA, USA
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Raman SR, Ford CB, Hammill BG, Clark AG, Clifton DC, Jackson GL. Non-overdose acute care hospitalizations for opioid use disorder among commercially-insured adults: a retrospective cohort study. Addict Sci Clin Pract 2023; 18:42. [PMID: 37434260 PMCID: PMC10337199 DOI: 10.1186/s13722-023-00396-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 06/26/2023] [Indexed: 07/13/2023] Open
Abstract
BACKGROUND Acute care inpatient admissions outside of psychiatric facilities have been increasingly identified as a critical touchpoint for opioid use disorder (OUD) treatment. We sought to describe non-opioid overdose hospitalizations with documented OUD and examine receipt of post-discharge outpatient buprenorphine. METHODS We examined acute care hospitalizations with an OUD diagnosis in any position within US commercially-insured adults age 18-64 years (IBM MarketScan claims, 2013-2017), excluding opioid overdose diagnoses. We included individuals with ≥ 6 months of continuous enrollment prior to the index hospitalization and ≥ 10 days following discharge. We described demographic and hospitalization characteristics, including outpatient buprenorphine receipt within 10 days of discharge. RESULTS Most (87%) hospitalizations with documented OUD did not include opioid overdose. Of 56,717 hospitalizations (49,959 individuals), 56.8% had a primary diagnosis other than OUD, 37.0% had documentation of an alcohol-related diagnosis code, and 5.8% end in a self-directed discharge. Where opioid use disorder was not the primary diagnosis, 36.5% were due to other substance use disorders, and 23.1% were due to psychiatric disorders. Of all non-overdose hospitalizations who had prescription medication insurance coverage and who were discharged to an outpatient setting (n = 49, 237), 8.8% filled an outpatient buprenorphine prescription within 10 days of discharge. CONCLUSIONS Non-overdose OUD hospitalizations often occur with substance use disorders and psychiatric disorders, and very few are followed by timely outpatient buprenorphine. Addressing the OUD treatment gap during hospitalization may include implementing medication for OUD for inpatients with a broad range of diagnoses.
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Affiliation(s)
- Sudha R Raman
- Department of Population Health Sciences, Duke University School of Medicine, 215 Morris Street, Suite 210, Durham, NC, 27701, USA.
| | - Cassie B Ford
- Department of Population Health Sciences, Duke University School of Medicine, 215 Morris Street, Suite 210, Durham, NC, 27701, USA
| | - Bradley G Hammill
- Department of Population Health Sciences, Duke University School of Medicine, 215 Morris Street, Suite 210, Durham, NC, 27701, USA
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, 2301 Erwin Road, Durham, NC, 27710, USA
| | - Amy G Clark
- Department of Population Health Sciences, Duke University School of Medicine, 215 Morris Street, Suite 210, Durham, NC, 27701, USA
| | - Dana C Clifton
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, 2301 Erwin Road, Durham, NC, 27710, USA
- Department of Pediatrics, Duke University School of Medicine, 2301 Erwin Road, Durham, NC, 27710, USA
| | - George L Jackson
- Department of Population Health Sciences, Duke University School of Medicine, 215 Morris Street, Suite 210, Durham, NC, 27701, USA
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, 2301 Erwin Road, Durham, NC, 27710, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham Veterans Affairs (VA) Health Care System, 508 Fulton Street, Durham, NC, 27705, USA
- Department of Family Medicine and Community Health, Duke University School of Medicine, 2100 Erwin Road, Durham, NC, 27705, USA
- Peter O'Donnell Jr. School of Public Health, University of Texas Southweatern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA
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Tucker K, Zikos D, Vick DJ. Association of Hospital Readmission Rates With Discharge Disposition for Patients With Psychotic Disorders. J Healthc Manag 2023; 68:198-214. [PMID: 37159018 DOI: 10.1097/jhm-d-22-00115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
GOAL We explored how readmissions may result from patients' lack of access to aftercare services, failure to adhere to psychotropic medication plans, and inability to understand and follow hospital discharge recommendations. We also investigated whether insurance status, demographics, and socioeconomic status are associated with hospital readmissions. This study is important because readmissions contribute to increased personal and hospital expenses and decreased community tenure (the ability to maintain stability between hospital admissions). Addressing hospital readmissions will promote optimal discharge practices beginning on day one of hospital admission. METHODS The study examined the differences in hospital readmission rates for patients with a primary psychotic disorder diagnosis. Discharge data were drawn in 2017 from the Nationwide Readmissions Database. Inclusion criteria included patients aged 0-89 years who were readmitted to a hospital between less than 24 hr and up to 30 days from discharge. Exclusion criteria were principal medical diagnoses, unplanned 30-day readmissions, and discharges against medical advice. The sampling frame included 269,906 weighted number of patients diagnosed with a psychotic disorder treated at one of 2,355 U.S. community hospitals. The sample size was 148,529 unweighted numbers of patients discharged. PRINCIPAL FINDINGS In a logistic regression model, weighted variables were calculated and used to determine an association between the discharge dispositions and readmissions. After controlling for hospital characteristics and patient demographics, we found that the odds for readmission for routine and short-term hospital discharge dispositions decreased for home health care discharges, which indicated that home health care can prevent readmissions. The finding was statistically significant when controlling for payer type and patient age and gender. PRACTICAL APPLICATIONS The findings support home health care as an effective option for patients with severe psychosis. Home health care reduces readmissions and is recommended, when appropriate, as an aftercare service following inpatient hospitalization and may enhance the quality of patient care. Improving healthcare quality involves optimizing, streamlining, and promoting standardized processes in discharge planning and direct transitions to aftercare services.
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Affiliation(s)
- Kariba Tucker
- School of Health Sciences, Central Michigan University, Mount Pleasant, Michigan
| | - Dimitrios Zikos
- School of Health Sciences and Herbert H. & Grace A. Dow College of Health Professions, Central Michigan University
| | - Dan J Vick
- School of Health Sciences and Herbert H. & Grace A. Dow College of Health Professions, Central Michigan University
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Waite MR, Heslin K, Cook J, Kim A, Simpson M. Predicting substance use disorder treatment follow-ups and relapse across the continuum of care at a single behavioral health center. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2023; 147:208933. [PMID: 36805798 DOI: 10.1016/j.josat.2022.208933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 10/11/2022] [Accepted: 12/30/2022] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Substance use disorder is often a chronic condition, and its treatment requires patient access to a continuum of care, including inpatient, residential, partial hospitalization, intensive outpatient, and outpatient programs. Ideally, patients complete treatment at the most suitable level for their immediate individual needs, then transition to the next appropriate level. In practice, however, attrition rates are high, as many patients discharge before successfully completing a treatment program or struggle to transition to follow-up care after program discharge. Previous studies analyzed up to two programs at a time in single-center datasets, meaning no studies have assessed patient attrition and follow-up behavior across all five levels of substance use treatment programs in parallel. METHODS To address this major gap, this retrospective study collected patient demographics, enrollment, discharge, and outcomes data across five substance use treatment levels at a large Midwestern psychiatric hospital from 2017 to 2019. Data analyses used descriptive statistics and regression analyses. RESULTS Analyses found several differences in treatment engagement based on patient-level variables. Inpatients were more likely to identify as Black or female compared to lower-acuity programs. Patients were less likely to step down in care if they were younger, Black, had Medicare coverage were discharging from inpatient treatment, or had specific behavioral health diagnoses. Patients were more likely to relapse if they were male or did not engage in follow-up SUD treatment. CONCLUSIONS Future studies should assess mechanisms by which these variables influence treatment access, develop programmatic interventions that encourage appropriate transitions between programs, and determine best practices for increasing access to treatment.
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Affiliation(s)
- Mindy R Waite
- Advocate Aurora Behavioral Health Services, Advocate Aurora Health, 1220 Dewey Ave, Wauwatosa, WI 53213, USA; Advocate Aurora Research Institute, Advocate Aurora Health, 960 N 12th St, Milwaukee, WI 53233, USA.
| | - Kayla Heslin
- Advocate Aurora Research Institute, Advocate Aurora Health, 960 N 12th St, Milwaukee, WI 53233, USA.
| | - Jonathan Cook
- Advocate Aurora Research Institute, Advocate Aurora Health, 960 N 12th St, Milwaukee, WI 53233, USA.
| | - Aengela Kim
- Advocate Aurora Research Institute, Advocate Aurora Health, 960 N 12th St, Milwaukee, WI 53233, USA; Chicago Medical School, Rosalind Franklin University, 3333 Green Bay Rd, North Chicago, IL 60064, USA.
| | - Michelle Simpson
- Advocate Aurora Research Institute, Advocate Aurora Health, 960 N 12th St, Milwaukee, WI 53233, USA; AAH Ed Howe Center for Health Care Transformation, Advocate Aurora Health, 960 N 12th St, Milwaukee, WI 53233, USA.
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Individual factors predict substance use treatment course patterns among patients in community-based substance use disorder treatment. PLoS One 2023; 18:e0280407. [PMID: 36634070 PMCID: PMC9836276 DOI: 10.1371/journal.pone.0280407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 12/28/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Substance use disorders (SUDs) usually involve a complex natural trajectory of recovery alternating with symptom reoccurrence. This study examined treatment course patterns over time in a community SUD clinic. We examined depressive symptoms level, primary SUD assigned at each admission, and lifetime misuse of multiple substances as potential risk factors for premature treatment termination and subsequent treatment readmission. METHODS De-identified longitudinal data were extracted from charts of 542 patients from an SUD treatment center. Survival analysis methods were applied to predict two time-to-event outcomes: premature treatment termination and treatment readmission. RESULTS Primary opioid (vs alcohol) use disorder diagnosis at admission was associated with higher hazard of premature termination (HR = 1.91, p<0.001). The interaction between depressive symptoms level and substance use status (multiple vs single use) on treatment readmission was significant (p = 0.024), such that higher depressive symptoms level was predictive of readmission only among those with a history of single substance use (marginally significant effect). Lifetime use of multiple (vs single) substances (HR = 1.55, p = 0.002) and age (HR = 1.01, p = 0.019) predicted increased hazard of readmission. CONCLUSIONS Findings did not support a universal role for depressive symptoms level in treatment course patterns. Primary SUD diagnosis, age, and history of substance misuse can be easily assessed and incorporated into treatment planning to support SUD patients and families. This study is the first to our knowledge that afforded a stringent test of these relationships and their interactions in a time-dependent, recurrent event, competing risks survival analysis examining both termination and readmission patterns utilizing a real-world clinic-based sample.
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Cole ES, Allen L, Austin A, Barnes A, Chang CCH, Clark S, Crane D, Cunningham P, Fry CE, Gordon AJ, Hammerslag L, Idala D, Kennedy S, Kim JY, Krishnan S, Lanier P, Mahakalanda S, Mauk R, McDuffie MJ, Mohamoud S, Talbert J, Tang L, Zivin K, Donohue JM. Outpatient follow-up and use of medications for opioid use disorder after residential treatment among Medicaid enrollees in 10 states. Drug Alcohol Depend 2022; 241:109670. [PMID: 36332591 PMCID: PMC10756712 DOI: 10.1016/j.drugalcdep.2022.109670] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 10/04/2022] [Accepted: 10/18/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Follow-up after residential treatment is considered best practice in supporting patients with opioid use disorder (OUD) in their recovery. Yet, little is known about rates of follow-up after discharge. The objective of this analysis was to measure rates of follow-up and use of medications for OUD (MOUD) after residential treatment among Medicaid enrollees in 10 states, and to understand the enrollee and episode characteristics that are associated with both outcomes. METHODS Using a distributed research network to analyze Medicaid claims data, we estimated the likelihood of 4 outcomes occurring within 7 and 30 days post-discharge from residential treatment for OUD using multinomial logit regression: no follow-up or MOUD, follow-up visit only, MOUD only, or both follow-up and MOUD. We used meta-analysis techniques to pool state-specific estimates into global estimates. RESULTS We identified 90,639 episodes of residential treatment for OUD for 69,017 enrollees from 2018 to 2019. We found that 62.5% and 46.9% of episodes did not receive any follow-up or MOUD at 7 days and 30 days, respectively. In adjusted analyses, co-occurring mental health conditions, longer lengths of stay, prior receipt of MOUD or behavioral health counseling, and a recent ED visit for OUD were associated with a greater likelihood of receiving follow-up treatment including MOUD after discharge. CONCLUSIONS Forty-seven percent of residential treatment episodes for Medicaid enrollees are not followed by an outpatient visit or MOUD, and thus are not following best practices.
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Affiliation(s)
- Evan S Cole
- University of Pittsburgh, A616, 130 DeSoto Street, Pittsburgh, PA 15261, USA
| | | | - Anna Austin
- University of North Carolina - Chapel Hill, Chapel Hill, NC, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | - Paul Lanier
- University of North Carolina - Chapel Hill, Chapel Hill, NC, USA
| | | | | | | | | | | | - Lu Tang
- University of Pittsburgh, Pittsburgh, PA, USA
| | - Kara Zivin
- University of Michigan, Ann Arbor, MI, USA
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Kumar V, Dolan RD, Yang AL, Jin DX, Banks PA, McNabb-Baltar J. Characteristics of 30-Day All-Cause Hospital Readmissions Among Patients with Acute Pancreatitis and Substance Use. Dig Dis Sci 2022; 67:5500-5510. [PMID: 35348968 DOI: 10.1007/s10620-022-07463-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 02/10/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND/OBJECTIVES Previous studies on healthcare resource utilization and 30-day readmission risks among patients with acute pancreatitis (AP) have focused upon opioid and alcohol use. The data on other substance types are lacking. In this study we aim to estimate the 30-day readmission rates, predictors of readmission, impact of readmission on patient outcomes and resulting economic burden among patients with AP and substance use in the USA. METHODS This was a retrospective cohort study, based upon data from 2017 National Readmission Database of adult patients with AP and substance use (alcohol in combination, opioid, cannabis, cocaine, sedatives, other stimulants, other hallucinogens, other psychoactive, inhalant and miscellaneous). We estimated the 30-day readmission rates and predictors of 30-day readmission. RESULTS Among 25,795 eligible patients, most were male, belonged to the lower income quartile, resided in the urban facility and had a Charlson comorbidity score of 0 or 1. The use of a combination of substances was the most common in 17,265 (66.9%) patients followed by only opioids in 4691 (18.2%) patients and only marijuana in 3839 (14.9%) patients. A total of 14.6% patients were readmitted within 30 days after discharge for non-elective causes with the highest risk of readmission within the 1st week after discharge with 5.2% readmissions. Among top ten causes of readmission, most of the principal diagnosis were related to AP in 53.1%. Compared to index admission, readmitted patients had significantly higher rates of acute cardiac failure, shock, and higher in-hospital mortality rate. Overall, readmission attributed to an additional 17,801 days of hospitalization resulting in a total of $150 million in hospitalization charges and $36 million in hospitalization costs in 2017. On multivariate analysis, chronic pancreatitis, self-discharge against medical advice, treatment at the highest volume centers, higher Charlson comorbidity index, increasing length of stay and severe disease were associated with higher odds of readmission while female gender and private insurance were associated with lower odds. CONCLUSION Readmission was associated with higher morbidity and in-hospital mortality among patients with AP and substance use and resulted in a significant monetary burden on the US healthcare system. Several factors identified in this study may be useful for categorizing patients at higher risk of readmission warranting special attention during discharge planning.
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Affiliation(s)
- Vivek Kumar
- Department of General Internal Medicine, Brigham and Women's Hospital Harvard Medical School, Boston, MA, USA
| | - Russell D Dolan
- Division of Gastroenterology, Hepatology, and Endoscopy, Center for Pancreatic Disease, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Allison L Yang
- Division of Gastroenterology, Weill Cornell Medical College and New York Presbyterian Hospital/Weill Cornell Medical Center, New York, NY, USA
| | - David X Jin
- Division of Gastroenterology, Hepatology, and Endoscopy, Center for Pancreatic Disease, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Peter A Banks
- Division of Gastroenterology, Hepatology, and Endoscopy, Center for Pancreatic Disease, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Julia McNabb-Baltar
- Division of Gastroenterology, Hepatology, and Endoscopy, Center for Pancreatic Disease, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.
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Alegría M, Falgas-Bague I, Fukuda M, Zhen-Duan J, Weaver C, O’Malley I, Layton T, Wallace J, Zhang L, Markle S, Lincourt P, Hussain S, Lewis-Fernández R, John DA, McGuire T. Racial/Ethnic Disparities in Substance Use Treatment in Medicaid Managed Care in New York City: The Role of Plan and Geography. Med Care 2022; 60:806-812. [PMID: 36038524 PMCID: PMC9588705 DOI: 10.1097/mlr.0000000000001768] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim was to assess the magnitude of health care disparities in treatment for substance use disorder (SUD) and the role of health plan membership and place of residence in observed disparities in Medicaid Managed Care (MMC) plans in New York City (NYC). DATA SOURCE Medicaid claims and managed care plan enrollment files for 2015-2017 in NYC. RESEARCH DESIGN We studied Medicaid enrollees with a SUD diagnosis during their first 6 months of enrollment in a managed care plan in 2015-2017. A series of linear regression models quantified service disparities across race/ethnicity for 5 outcome indicators: treatment engagement, receipt of psychosocial treatment, follow-up after withdrawal, rapid readmission, and treatment continuation. We assessed the degree to which plan membership and place of residence contributed to observed disparities. RESULTS We found disparities in access to treatment but the magnitude of the disparities in most cases was small. Plan membership and geography of residence explained little of the observed disparities. One exception is geography of residence among Asian Americans, which appears to mediate disparities for 2 of our 5 outcome measures. CONCLUSIONS Reallocating enrollees among MMC plans in NYC or evolving trends in group place of residence are unlikely to reduce disparities in treatment for SUD. System-wide reforms are needed to mitigate disparities.
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Affiliation(s)
- Margarita Alegría
- Disparities Research Unit, Massachusetts General Hospital, Boston, MA
- Department of Medicine, Harvard Medical School, Boston, MA
- Department of Psychiatry, Harvard Medical School, Boston, MA
| | - Irene Falgas-Bague
- Disparities Research Unit, Massachusetts General Hospital, Boston, MA
- Department of Medicine, Harvard Medical School, Boston, MA
| | - Marie Fukuda
- Disparities Research Unit, Massachusetts General Hospital, Boston, MA
| | - Jenny Zhen-Duan
- Disparities Research Unit, Massachusetts General Hospital, Boston, MA
- Department of Medicine, Harvard Medical School, Boston, MA
| | - Cole Weaver
- Department of Health Care Policy, Harvard Medical School, Boston, MA
| | - Isabel O’Malley
- Disparities Research Unit, Massachusetts General Hospital, Boston, MA
| | - Timothy Layton
- Department of Health Care Policy, Harvard Medical School, Boston, MA
| | | | - Lulu Zhang
- Disparities Research Unit, Massachusetts General Hospital, Boston, MA
| | - Sheri Markle
- Disparities Research Unit, Massachusetts General Hospital, Boston, MA
| | - Pat Lincourt
- New York State Office of Alcoholism and Substance Abuse Services, Albany, NY
| | - Shazia Hussain
- New York State Office of Alcoholism and Substance Abuse Services, Albany, NY
| | - Roberto Lewis-Fernández
- Department of Psychiatry, Columbia University, New York, NY
- New York State Psychiatric Institute, New York, NY
| | | | - Thomas McGuire
- Department of Health Care Policy, Harvard Medical School, Boston, MA
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Matlick GL, Delaney KR. Evaluation of Psychiatric Rehospitalization of Individuals Treated at a Federally Qualified Health Center. Issues Ment Health Nurs 2022; 43:1041-1045. [PMID: 36150111 DOI: 10.1080/01612840.2022.2124005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
At a federally qualified health center which often receives discharge referrals from the local hospital, rehospitalization rates and reasons were unknown yet pertinent information for assuring timely follow-up appointments. This study examined psychiatric discharge and rehospitalization between August 2020 and January 2021. Between August and October 2020, all adult patients of the FQHC were investigated who presented to or were discharged from the hospital. Those who received a primary psychiatric diagnosis were then examined retrospectively (between November 2020 and January 2021) to determine readmission status. During the study period, 36 patients were hospitalized with primary psychiatric diagnoses, 81% of whom did not establish behavioral health care subsequent to their initial hospitalization. The overall 90-day readmission rate of the sample was 41.7% with 80% of these individuals returning within 30 days.
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Affiliation(s)
- Garrett L Matlick
- College of Nursing, Department of Community, Systems and Mental Health, Rush University, Chicago, Illinois, USA
| | - Kathleen R Delaney
- College of Nursing, Department of Community, Systems and Mental Health, Rush University, Chicago, Illinois, USA
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12
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Jimenez AE, Cicalese KV, Chakravarti S, Porras JL, Azad TD, Jackson CM, Gallia G, Bettegowda C, Weingart J, Mukherjee D. Substance Use Disorders Are Independently Associated with Hospital Readmission Among Patients with Brain Tumors. World Neurosurg 2022; 166:e358-e368. [PMID: 35817348 DOI: 10.1016/j.wneu.2022.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 07/02/2022] [Accepted: 07/04/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Research on the effects of substance use disorders (SUDs) on postoperative outcomes within neurosurgical oncology has been limited. Therefore, the present study sought to quantify the effect of having a SUD on hospital length of stay, postoperative complication incidence, discharge disposition, hospital charges, 90-day readmission rates, and 90-day mortality rates following brain tumor surgery. METHODS The present study used data from patients who received surgical resection for brain tumor at a single institution between January 1, 2017, and December 31, 2019. The Mann-Whitney U test was used for bivariate analysis of continuous variables and Fisher exact test was used for bivariate analysis of categorical variables. Multivariate analysis was conducted using logistic regression models. RESULTS Our study cohort included a total of 2519 patients, 124 (4.9%) of whom had at least 1 SUD. More specifically, 90 (3.6%) patients had an alcohol use disorder, 27 (1.1%) had a cannabis use disorder, and 12 (0.5%) had an opioid use disorder. On bivariate analysis, 90-day hospital readmission was the only postoperative outcome significantly associated with a SUD (odds ratio 2.21, P = 0.0011). When controlling for patient age, sex, race, marital status, insurance, brain tumor diagnosis, 5-factor modified frailty index score, American Society of Anesthesiologists score, and surgery number, SUDs remained significantly and independently associated with 90-day readmission (odds ratio 1.82, P = 0.013). CONCLUSIONS In patients with brain tumor, SUDs significantly and independently predict 90-day hospital readmission after surgery. Targeted management of patients with SUDs before and after surgery can optimize patient outcomes and improve the provision of high-value neurosurgical care.
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Affiliation(s)
- Adrian E Jimenez
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kyle V Cicalese
- Department of Neurosurgery, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Sachiv Chakravarti
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jose L Porras
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Tej D Azad
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Christopher M Jackson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Gary Gallia
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Chetan Bettegowda
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jon Weingart
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Debraj Mukherjee
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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13
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Owusu E, Oluwasina F, Nkire N, Lawal MA, Agyapong VIO. Readmission of Patients to Acute Psychiatric Hospitals: Influential Factors and Interventions to Reduce Psychiatric Readmission Rates. Healthcare (Basel) 2022; 10:healthcare10091808. [PMID: 36141418 PMCID: PMC9498532 DOI: 10.3390/healthcare10091808] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 08/24/2022] [Accepted: 09/14/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Appropriate and adequate treatment of psychiatric conditions in the community or at first presentation to the hospital may prevent rehospitalization. Information about hospital readmission factors may help to reduce readmission rates. This scoping review sought to examine the readmission of patients to acute psychiatric hospitals to determine predictors and interventions to reduce psychiatric readmission rates. Method: A scoping review was conducted in eleven bibliographic databases to identify the relevant peer-reviewed studies. Two reviewers independently assessed full-text articles, and a screening process was undertaken to identify studies for inclusion in the review. PRISMA checklist was adopted, and with the Covidence software, 75 articles were eligible for review. Data extraction was conducted, collated, summarized, and findings reported. Result: 75 articles were analyzed. The review shows that learning disabilities, developmental delays, alcohol, drug, and substance abuse, were crucial factors that increased the risk of readmission. Greater access to mental health services in residential treatment and improved crisis intervention in congregate care settings were indicated as factors that reduce the risk of readmission. Conclusion: High rates of readmission may adversely impact healthcare spending. This study suggests a need for focused health policies to address readmission factors and improve community-based care.
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Affiliation(s)
- Ernest Owusu
- Department of Psychiatry, University of Alberta, Edmonton, AB T6W 3W8, Canada
- Correspondence: ; Tel.: +1-780-710-2393
| | - Folajinmi Oluwasina
- Department of Psychiatry, University of Alberta, Edmonton, AB T6W 3W8, Canada
| | - Nnamdi Nkire
- Department of Psychiatry, University of Alberta, Edmonton, AB T6W 3W8, Canada
| | - Mobolaji A. Lawal
- Department of Psychiatry, University of Alberta, Edmonton, AB T6W 3W8, Canada
| | - Vincent I. O. Agyapong
- Department of Psychiatry, University of Alberta, Edmonton, AB T6W 3W8, Canada
- Department of Psychiatry, Dalhousie University, Halifax, NS B3H 4R2, Canada
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14
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Gardner RL, Baier RR, Cooper EL, Clements EE, Belanger E. Interventions to Reduce Hospital and Emergency Department Utilization Among People With Alcohol and Substance Use Disorders: A Scoping Review. Med Care 2022; 60:164-177. [PMID: 34908009 DOI: 10.1097/mlr.0000000000001676] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Substance use disorders (SUDs), prevalent worldwide, are associated with significant morbidity and health care utilization. OBJECTIVES To identify interventions addressing hospital and emergency department utilization among people with substance use, to summarize findings for those seeking to implement such interventions, and to articulate gaps that can be addressed by future research. RESEARCH DESIGN A scoping review of the literature. We searched PubMed, PsycInfo, and Google Scholar for any articles published from January 2010 to June 2020. The main search terms included the target population of adults with substance use or SUDs, the outcomes of hospital and emergency department utilization, and interventions aimed at improving these outcomes in the target population. SUBJECTS Adults with substance use or SUDs, including alcohol use. MEASURES Hospital and emergency department utilization. RESULTS Our initial search identified 1807 titles, from which 44 articles were included in the review. Most interventions were implemented in the United States (n=35). Half focused on people using any substance (n=22) and a quarter on opioids (n=12). The tested approaches varied and included postdischarge services, medications, legislation, and counseling, among others. The majority of study designs were retrospective cohort studies (n=31). CONCLUSIONS Overall, we found few studies assessing interventions to reduce health care utilization among people with SUDs. The studies that we did identify differed across multiple domains and included few randomized trials. Study heterogeneity limits our ability to compare interventions or to recommend one specific approach to reducing health care utilization among this high-risk population.
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Affiliation(s)
- Rebekah L Gardner
- Department of Medicine, Alpert Medical School of Brown University
- Healthcentric Advisors
| | - Rosa R Baier
- Center for Long-Term Care Quality & Innovation
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI
| | | | - Erin E Clements
- Public Health Program, Brown University School of Public Health
| | - Emmanuelle Belanger
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI
- Center for Gerontology & Healthcare Research, Brown University School of Public Health, Providence, RI
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15
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Schmidt EM, Wright D, Cherkasova E, Harris AHS, Trafton J. Evaluating and Improving Engagement in Care After High-Intensity Stays for Mental or Substance Use Disorders. Psychiatr Serv 2022; 73:18-25. [PMID: 34106740 DOI: 10.1176/appi.ps.202000287] [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] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This interrupted time-series analysis examined whether activating a quality measure, supported by education and a population management tool, was associated with higher postdischarge engagement (PDE) in outpatient care after inpatient and residential stays for mental or substance use disorder care. METHODS Discharges from October 2016 to May 2019 were identified from national Veterans Health Administration (VHA) records representing all 140 VHA health care systems. Engagement was defined as multiple mental or substance use disorder outpatient visits in the 30 days postdischarge. The number of such visits required to meet the engagement definition depended on a patient's suicide risk and acuity level of inpatient or residential treatment. Health care system-level performance was calculated as the percentage of qualifying discharges with 30-day PDE. A segmented mixed-effects linear regression model tested whether monthly health care system performance changed significantly after activation of the PDE measure (activation rollout period, October-December 2017). RESULTS A total of 322,344 discharges qualified for the measure. In the regression model, average health care system performance was 65.6% at the beginning of the preactivation period (October 2016) and did not change significantly in the following 12 months. Average health care system performance increased by 5.7% (SE=0.8%, p<0.001) after PDE measure activation and did not change significantly thereafter-a difference representing 11,464 more patients engaging in care than would have without activation of the measure. CONCLUSIONS Results support use of this measure, along with education, technical assistance, and population management tools, to improve engagement after discharge from residential and inpatient mental and substance use disorder treatment.
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Affiliation(s)
- Eric M Schmidt
- Program Evaluation and Resource Center, Office of Mental Health and Suicide Prevention, Veterans Health Administration (VHA), U.S. Department of Veterans Affairs (VA), Menlo Park, California (Schmidt, Wright, Cherkasova, Trafton); Center for Innovation to Implementation, Health Services Research and Development (HSR&D), VHA, VA Palo Alto Health Care System, Menlo Park, California (Schmidt, Harris); Department of Surgery (Harris) and Department of Psychiatry and Behavioral Sciences (Trafton), School of Medicine, Stanford University, Stanford, California
| | - David Wright
- Program Evaluation and Resource Center, Office of Mental Health and Suicide Prevention, Veterans Health Administration (VHA), U.S. Department of Veterans Affairs (VA), Menlo Park, California (Schmidt, Wright, Cherkasova, Trafton); Center for Innovation to Implementation, Health Services Research and Development (HSR&D), VHA, VA Palo Alto Health Care System, Menlo Park, California (Schmidt, Harris); Department of Surgery (Harris) and Department of Psychiatry and Behavioral Sciences (Trafton), School of Medicine, Stanford University, Stanford, California
| | - Elena Cherkasova
- Program Evaluation and Resource Center, Office of Mental Health and Suicide Prevention, Veterans Health Administration (VHA), U.S. Department of Veterans Affairs (VA), Menlo Park, California (Schmidt, Wright, Cherkasova, Trafton); Center for Innovation to Implementation, Health Services Research and Development (HSR&D), VHA, VA Palo Alto Health Care System, Menlo Park, California (Schmidt, Harris); Department of Surgery (Harris) and Department of Psychiatry and Behavioral Sciences (Trafton), School of Medicine, Stanford University, Stanford, California
| | - Alex H S Harris
- Program Evaluation and Resource Center, Office of Mental Health and Suicide Prevention, Veterans Health Administration (VHA), U.S. Department of Veterans Affairs (VA), Menlo Park, California (Schmidt, Wright, Cherkasova, Trafton); Center for Innovation to Implementation, Health Services Research and Development (HSR&D), VHA, VA Palo Alto Health Care System, Menlo Park, California (Schmidt, Harris); Department of Surgery (Harris) and Department of Psychiatry and Behavioral Sciences (Trafton), School of Medicine, Stanford University, Stanford, California
| | - Jodie Trafton
- Program Evaluation and Resource Center, Office of Mental Health and Suicide Prevention, Veterans Health Administration (VHA), U.S. Department of Veterans Affairs (VA), Menlo Park, California (Schmidt, Wright, Cherkasova, Trafton); Center for Innovation to Implementation, Health Services Research and Development (HSR&D), VHA, VA Palo Alto Health Care System, Menlo Park, California (Schmidt, Harris); Department of Surgery (Harris) and Department of Psychiatry and Behavioral Sciences (Trafton), School of Medicine, Stanford University, Stanford, California
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16
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Ghosh A, Sharma N, Noble D, Basu D, Mattoo SK, Bn S, Pillai RR. Predictors of Five-Year Readmission to an Inpatient Service among Patients with Alcohol Use Disorders: Report from a Low-Middle Income Country. Subst Use Misuse 2022; 57:123-133. [PMID: 34668819 DOI: 10.1080/10826084.2021.1990341] [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] [Indexed: 10/20/2022]
Abstract
BACKGROUND Alcohol use disorder (AUD) is a relapsing-remitting disease that accounted for a sizable proportion of all-cause adult inpatient stays. OBJECTIVES To determine the predictors of any and multiple readmissions to inpatient care for AUD within 5 years of the index admission. METHODS This retrospective, register-based cohort study assessed consecutive patients with AUD admitted to a publicly-funded inpatient service between January 2007 and December 2014. Binary logistic regression was used to determine independent predictors for readmissions based on relevant demographic, clinical, and treatment variables that showed significant differences (p < 0.05) on univariate analysis. RESULTS Among 938 patients (age 35.9 ± 10.3 years; duration of alcohol use 159.6 ± 104.5 months; dual diagnosis 19%; comorbidity of substance use disorder 49.3%; medical disorder 34.8%, 299 (31.9%) and 115 (12.3%) had any and multiple readmissions, respectively. Comorbid "severe mental illness" (Odds ratio [OR] 1.99, 95% confidence interval [CI] 1.11-3.57) and urban residence (OR 1.58, 95% CI 1.13-2.18) increased the odds of any readmission; "Improved" status at discharge (OR 0.51, 95% CI 0.35-0.72) during index hospitalization reduced odds of readmission. Additionally, any medical or psychiatric comorbidities increased (OR 2.23, 95% CI 1.26-3.97), and comorbid substance use disorder decreased (OR 0.41, 95% CI 0.19-0.89) risk of multiple readmissions. CONCLUSIONS Clinicians could identify patients at-risk for any and multiple readmissions during the index hospitalization. A policy aimed at reducing the risk of rehospitalization, healthcare cost, and stigma should pay attention to the predictors of readmission. Such policy should further benefit resource-limited settings.
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Affiliation(s)
- Abhishek Ghosh
- Drug De-addiction & Treatment Centre & Department of Psychiatry, Postgraduate Institute of medical Education & Research, Chandigarh, Chandigarh, India
| | - Nidhi Sharma
- Department of Psychiatry, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India
| | - Dalton Noble
- Department of Psychiatry, IVY Hospital, Nawanshahr, Punjab, India
| | - Debasish Basu
- Drug De-addiction & Treatment Centre & Department of Psychiatry, Postgraduate Institute of medical Education & Research, Chandigarh, Chandigarh, India
| | - S K Mattoo
- Consultant Psychiatrist, Community Mental Health Clinic, Cumbria Northumberland Tyne and Wear Foundation NHS Trust, Molineux NHS Centre, Byker, Newcastle Upon Tyne, UK
| | - Subodh Bn
- Drug De-addiction & Treatment Centre & Department of Psychiatry, Postgraduate Institute of medical Education & Research, Chandigarh, Chandigarh, India
| | - R R Pillai
- Drug De-addiction & Treatment Centre & Department of Psychiatry, Postgraduate Institute of medical Education & Research, Chandigarh, Chandigarh, India
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The Substance Use Treatment and Recovery Team (START) study: protocol for a multi-site randomized controlled trial evaluating an intervention to improve initiation of medication and linkage to post-discharge care for hospitalized patients with opioid use disorder. Addict Sci Clin Pract 2022; 17:39. [PMID: 35902888 PMCID: PMC9331017 DOI: 10.1186/s13722-022-00320-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 07/01/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND People with opioid use disorder experience high burden of disease from medical comorbidities and are increasingly hospitalized with medical complications. Medications for opioid use disorder are an effective, life-saving treatment, but patients with an opioid use disorder admitted to the hospital seldom initiate medication for their disorder while in the hospital, nor are they linked with outpatient treatment after discharge. The inpatient stay, when patients may be more receptive to improving their health and reducing substance use, offers an opportunity to discuss opioid use disorder and facilitate medication initiation and linkage to treatment after discharge. An addiction-focus consultative team that uses evidence-based tools and resources could address barriers, such as the need for the primary medical team to focus on the primary health problem and lack of time and expertise, that prevent primary medical teams from addressing substance use. METHODS This study is a pragmatic randomized controlled trial that will evaluate whether a consultative team, called the Substance Use Treatment and Recovery Team (START), increases initiation of any US Food and Drug Administration approved medication for opioid use disorder (buprenorphine, methadone, naltrexone) during the hospital stay and increases linkage to treatment after discharge compared to patients receiving usual care. The study is being conducted at three geographically distinct academic hospitals. Patients are randomly assigned within each hospital to receive the START intervention or usual care. Primary study outcomes are initiation of medication for opioid use disorder in the hospital and linkage to medication or other opioid use disorder treatment after discharge. Outcomes are assessed through participant interviews at baseline and 1 month after discharge and data from hospital and outpatient medical records. DISCUSSION The START intervention offers a compelling model to improve care for hospitalized patients with opioid use disorder. The study could also advance translational science by identifying an effective and generalizable approach to treating not only opioid use disorder, but also other substance use disorders and behavioral health conditions. TRIAL REGISTRATION Clinicaltrials.gov: NCT05086796, Registered on 10/21/2021. https://www. CLINICALTRIALS gov/ct2/results?recrs=ab&cond=&term=NCT05086796&cntry=&state=&city=&dist = .
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Lavoie J, Phillips-Beck W, Kinew KA, Kyoon-Achan G, Katz A. First Nations' hospital readmission ending in death: a potential sentinel indicator of inequity? Int J Circumpolar Health 2021; 80:1859824. [PMID: 33308085 PMCID: PMC7738285 DOI: 10.1080/22423982.2020.1859824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 09/17/2020] [Accepted: 09/22/2020] [Indexed: 11/04/2022] Open
Abstract
In this study, we focused on readmissions for Ambulatory Care Sensitive Conditions (ACSC) ending in death, to capture those admissions and readmissions that might have been prevented if responsive primary healthcare was accessible. We propose this as a sentinel indicator of equity. We conducted analyses of Manitoba-based 30-day hospital readmission rates for ACSC which resulted in death, using data from 1986-2016 adjusted for age, sex, and socio-economic status. Our findings show that, across Manitoba, overall rates of readmissions ending in death are slowly increasing, and increasing more dramatically among northern First Nations, larger First Nations not affiliated with Tribal Councils, and in the western region of the province. These regions have continuously been highlighted as disadvantaged in terms of access to care, suggesting that the time for action is overdue. Rising rates of readmissions for ACSC ending in death suggest that greater attention should be placed on access to responsive primary healthcare. These findings have broader implications for territorial healthcare systems which purchase acute care services from provinces south of them. As an indicator of quality, monitoring readmissions ending in death could provide territorial governments insights into the quality of care provided to their constituents by provincial authorities.
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Affiliation(s)
- Josée Lavoie
- Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | | | - Grace Kyoon-Achan
- Department of Community Health Science, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Alan Katz
- Manitoba Centre for Health Policy, University of Manitoba, Winnipeg, Manitoba, Canadag
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Vest NA, Rossi FS, Ilgen M, Humphreys K, Timko C. Substance Use, PTSD Symptoms, and Suicidal Ideation Among Veteran Psychiatry Inpatients: A Latent Class Trajectory Analysis. J Stud Alcohol Drugs 2021; 82:792-800. [PMID: 34762039 PMCID: PMC8819620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 06/05/2021] [Indexed: 02/15/2024] Open
Abstract
OBJECTIVE In this study, we aimed to inform clinical practice by identifying distinct subgroups of U.S. veteran psychiatry inpatients on their alcohol and drug use severity, posttraumatic stress disorder (PTSD) symptoms, and suicidal ideation over time. METHOD Participants were 406 patients with co-occurring substance use and mental health disorders. A parallel latent growth trajectory model was used to characterize participants' symptom severity across 15 months posttreatment intake. RESULTS Four distinct classes were identified: 47% "normative improvement," 32% "high PTSD," 11% "high drug use," and 9% "high alcohol use." Eighty percent of the sample had reduced their drinking and drug intake by half from baseline to 3 months, and those levels remained stable from 3 to 15 months. The High PTSD, High Drug Use, and High Alcohol Use classes all reported levels of PTSD symptomatology at baseline consistent with a clinical diagnosis, and symptom levels remained high and stable across all 15 months. The Normative Improvement class showed declining drug and alcohol intake and was the only class exhibiting reductions in PTSD symptomatology over time. High substance use classes showed initial declines in suicidal ideation, then an increase from 9 to 15 months. CONCLUSIONS The reduction in frequency of drinking and drug use for 80% of the sample was substantial and supports the potential efficacy of current treatment approaches. However, the high and stable levels of PTSD for more than 50% of the sample, as well as the reemergence of suicidal ideation in a sizable subgroup, underscore the difficulty in finding and linking patients to effective interventions to decrease symptomatology over time.
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Affiliation(s)
- Noel A. Vest
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California
| | - Fernanda S. Rossi
- Department of Veterans Affairs, Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Menlo Park, California
- Center for Health Policy/Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, California
| | - Mark Ilgen
- University of Michigan Department of Psychiatry, Ann Arbor, Michigan
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan
| | - Keith Humphreys
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California
- Department of Veterans Affairs, Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Menlo Park, California
| | - Christine Timko
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California
- Department of Veterans Affairs, Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Menlo Park, California
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Roy PJ, Price R, Choi S, Weinstein ZM, Bernstein E, Cunningham CO, Walley AY. Shorter outpatient wait-times for buprenorphine are associated with linkage to care post-hospital discharge. Drug Alcohol Depend 2021; 224:108703. [PMID: 33964730 PMCID: PMC8180499 DOI: 10.1016/j.drugalcdep.2021.108703] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 02/22/2021] [Accepted: 02/22/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Inpatient addiction consult services (ACS) lower barriers to accessing medications for opioid use disorder (MOUD), however not every patient recommended for MOUD links to outpatient care. We hypothesized that fewer days between discharge date and outpatient appointment date was associated with improved linkage to buprenorphine treatment among patients evaluated by an ACS. METHODS We extracted appointment and demographic data from electronic medical records and conducted retrospective chart review of adults diagnosed with opioid use disorder (OUD) evaluated by an ACS in Boston, MA between July 2015 and August 2017. These patients were initiated on or recommended buprenorphine treatment on discharge and provided follow-up appointment at our hospital post-discharge. Multivariable logistic regression assessed whether arrival to the appointment post-discharge was associated with shorter wait-times (0-1 vs. 2+ days). RESULTS In total, 142 patients were included. Among patients who had wait-times of 0-1 day, 63 % arrived to their appointment compared to wait-times of 2 or more days (42 %). There were no significant differences between groups based on age, gender, distance of residence from the hospital, insurance status, co-occurring alcohol use disorder diagnosis, or discharge with buprenorphine prescription. After adjusting for covariates, patients with 0-1 day of wait-time had 2.6 times the odds of arriving to their appointment [95 % CI 1.3-5.5] compared to patients who had 2+ days of wait-time. CONCLUSION For hospitalized patients with OUD evaluated for initiating MOUD, same- and next-day appointments are associated with increased odds of linkage to outpatient MOUD care post-discharge compared to waiting two or more days.
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Affiliation(s)
- Payel J Roy
- Department of Medicine, University of Pittsburgh School of Medicine, 200 Lothrop St, Pittsburgh, PA, 15213, USA.
| | - Ryan Price
- Department of Medicine, Boston University School of Medicine, 801 Massachusetts Ave, Boston, MA, 02118, USA
| | - Sugy Choi
- Department of Health Law, Policy, and Management, Boston University School of Public Health, 715 Albany St, Boston, MA, 02118, USA
| | - Zoe M Weinstein
- Department of Medicine, Boston University School of Medicine, 801 Massachusetts Ave, Boston, MA, 02118, USA
| | - Edward Bernstein
- Department of Community Health Sciences, Boston University School of Public Health, 715 Albany St, Boston, MA, 02118, USA; Department of Emergency Medicine, Boston University School of Medicine, 850 Harrison Ave, Boston, MA, 02118, USA
| | - Chinazo O Cunningham
- Department of Medicine, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY, 10461, USA
| | - Alexander Y Walley
- Department of Medicine, Boston University School of Medicine, 801 Massachusetts Ave, Boston, MA, 02118, USA
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21
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Williams CA, Haffizulla F. Factors Associated With Avoidable Emergency Department Visits in Broward County, Florida. Cureus 2021; 13:e15593. [PMID: 34277214 PMCID: PMC8272918 DOI: 10.7759/cureus.15593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2021] [Indexed: 11/25/2022] Open
Abstract
Background Improper utilization of emergency departments (EDs) in the United States is an issue that places a large burden on the healthcare system. Previous studies have shown that differences in race, gender, and income level have been associated with avoidable ED visits. Broward County, Florida, is diverse with people from many different socioeconomic backgrounds. The objective of this study is to determine the impact that race/ethnicity, gender, and payment methods have on the rates of avoidable ED visits at hospitals in Broward County, Florida. Methods This study utilized a dataset from the Broward Regional Health Planning Council that included ED visits in Broward County in 2019. Secondary data analysis was conducted utilizing a one-way analysis of variance (ANOVA) with post-hoc analysis to compare the proportions of non-emergent, emergent primary care-treatable, and emergent preventable ED visits amongst different race/ethnicities, genders, and payment/insurance methods. Results Compared to non-Hispanic white patients, non-Hispanic black and Hispanic patients had higher mean rates of non-emergent ED visits. Women had greater mean rates compared to men for non-emergent ED visits; males had higher mean rates than females for emergent primary care-treatable and emergent preventable. Patients covered by Medicaid had greater mean rates of non-emergent and emergent primary care-treatable visits compared to patients using other payment or insurance methods. Conclusions This study identified demographics within Broward County associated with avoidable ED visits. To reduce the burden of ED overutilization on the healthcare system, healthcare providers must better educate the at-risk populations about proper ED use. In addition, a comprehensive assessment of social determinants of health in patients overutilizing the ED will allow for better alignment of resources and policy changes to improve healthcare access and community health.
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Affiliation(s)
- Caitlin A Williams
- Emergency Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Allopathic Medicine, Fort Lauderdale, USA
| | - Farzanna Haffizulla
- Internal Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, USA
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22
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Tong B, Osborne C, Horwood CM, Hakendorf PH, Woodman RJ, Li JY. The prevalence, characteristics, and risk factors of frequently readmitted patients to an internal medicine service. Intern Med J 2021; 52:1561-1568. [PMID: 34031965 DOI: 10.1111/imj.15395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 04/07/2021] [Accepted: 04/24/2021] [Indexed: 11/28/2022]
Abstract
AIMS To determine the prevalence, characteristics and risk factors associated with frequent readmissions to an internal medicine service at a tertiary public hospital. METHOD A retrospective observational study was conducted at an internal medicine service in a tertiary teaching hospital between 1st January 2010 and the 30th June 2016. Frequent readmission was defined as four or more readmissions within 12 months of discharge from the index admission. Demographic and clinical characteristics, and potential risk factors were evaluated. RESULTS 50 515 patients were included, 1657 (3.3%) had frequent readmissions and were associated with nearly 2.5 times higher in 12-month mortality rates. They were older, had higher rates of Indigenous Australians (3.2%), more disadvantaged status (Index of Relative Socio-Economic Disadvantage decile of 5.3), and more comorbidities (mean Charlson comorbidity index 1.4) in comparison, to infrequent readmission group. The mean length of hospital stay during the index admission was 6 days for frequent readmission group (21.4% staying more than 7 days) with higher incidence of discharge against medical advice (2.0% higher). Intensive care unit admission rate was 6.6% for frequent readmission group compared to 3.9% for infrequent readmission group. Multivariate analysis showed mental disease and disorders, neoplastic, and alcohol/drug use and alcohol/drug induced organic mental disorders are associated with frequent readmission. CONCLUSION The risk factors associated with frequent readmission were older age, indigenous status, being socially disadvantaged, having higher comorbidities, and discharging against medical advice. Conditions that lead to frequent readmissions were mental disorders, alcohol/drug use and alcohol/drug induced organic mental disorders, and neoplastic disorders.
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Affiliation(s)
- Bcy Tong
- College of Medicine & Public Health, Flinders University, Adelaide, South Australia
| | - Cdi Osborne
- College of Medicine & Public Health, Flinders University, Adelaide, South Australia
| | - C M Horwood
- Department of Clinical Epidemiology, Flinders Medical Centre, Adelaide, South Australia
| | - P H Hakendorf
- Department of Clinical Epidemiology, Flinders Medical Centre, Adelaide, South Australia
| | - R J Woodman
- College of Medicine & Public Health, Flinders University, Adelaide, South Australia.,Centre for Epidemiology and Biostatistics, College of Medicine & Public Health, Flinders University, Adelaide, South Australia
| | - J Y Li
- College of Medicine & Public Health, Flinders University, Adelaide, South Australia.,Department of Renal Medicine, Flinders Medical Centre, Adelaide, South Australia
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Association between discharges against medical advice and readmission in patients treated for drug injection-related skin and soft tissue infections. J Subst Abuse Treat 2021; 126:108465. [PMID: 34116815 DOI: 10.1016/j.jsat.2021.108465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 01/08/2021] [Accepted: 04/30/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND The prevalence of injection drug use (IDU)-related skin and soft tissue infections (SSTI) in Philadelphia has been steadily increasing since 2013. Patients seeking treatment for these infections are more likely to be discharged against medical advice (AMA), increasing the likelihood that they will end antibiotic treatment prematurely and require additional medical interventions. METHODS The research team performed a nested case-control study using the Pennsylvania Health Care Cost Containment Council database for Philadelphia residents hospitalized for SSTI and substance use-related diagnoses between 2013 and 2018. The primary outcome was readmission in the same or following quarter. The study examined the impact of discharge AMA on readmission along with clinical characteristics including diagnoses for anxiety, bipolar disorder, depression, schizophrenia, diabetes, and polydrug use. RESULTS There were 8265 hospitalizations for IDU-related SSTI and 316 (6%) were readmitted to the hospital at least once in the same or following quarter. In total, 23.4% of cases and 13% of controls left AMA. In the final multivariable regression model, AMA discharge (AOR 2.04, 95% CI 1.46-2.86), anxiety (AOR 1.44, 95% CI 1.01-2.05), diabetes (AOR 2.02, 95% CI 1.46-2.81), and polydrug use (AOR 2.11, 95% CI 1.52-2.92) were associated with higher odds of readmission. CONCLUSIONS Our study demonstrates that readmissions for IDU-related SSTI are associated with recent discharge AMA. As IDU-related SSTI and polydrug use continue to rise, premature antibiotic treatment completion will impact more people, leading to worse health outcomes and additional strain on the health care system.
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24
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Kirchoff RW, Mohammed NM, McHugh J, Markota M, Kingsley T, Leung J, Burton MC, Chaudhary R. Naltrexone Initiation in the Inpatient Setting for Alcohol Use Disorder: A Systematic Review of Clinical Outcomes. Mayo Clin Proc Innov Qual Outcomes 2021; 5:495-501. [PMID: 33997645 PMCID: PMC8105524 DOI: 10.1016/j.mayocpiqo.2021.01.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Alcohol use disorder (AUD) is a highly prevalent health issue in the United States. The number of those receiving medication-assisted treatment (MAT) is limited, despite strong evidence for their effectiveness. The inpatient setting may represent an important opportunity to initiate MAT. The goal of this study was to summarize the data on naltrexone initiation in the emergency department or inpatient setting for the management of AUDs. We searched ClinicalTrials.gov, Ovid EBM Reviews, Ovid Embase, Ovid Medline, Ovid PsycINFO, Scopus, and Web of Science from inception through October 31, 2019. Search strategies were created using a combination of keywords (Supplemental Appendix 1, available online at http://www.mcpiqojournal.org) and standardized index terms related to naltrexone therapy for medically hospitalized patients with AUD. Two uncontrolled pre-post study designs evaluated naltrexone prescription rates, 30-day readmission rates, and rehospitalization rates. Two authors independently abstracted data on study characteristics, results, and study-level risk of bias. The research team collaborated to assess the strength of evidence across studies. Two studies reported that implementing a protocol for naltrexone initiation increased MAT rates, with one study noting a substantial decrease in 30-day hospital readmissions. Overall, we found that there is a paucity of data on naltrexone initiation in the inpatient setting for AUDs. This likely reflects the nature of current clinical practice and prescriber comfortability. There is a need for further studies evaluating MAT initiation in the inpatient setting. Furthermore, efforts to increase provider knowledge of these therapeutic options are in need of further exploration.
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Affiliation(s)
| | | | - Jack McHugh
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Matej Markota
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota
| | - Thomas Kingsley
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Jonathan Leung
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota
| | | | - Rahul Chaudhary
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
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25
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Barriers and Facilitators to the Use of Medications for Opioid Use Disorder: a Rapid Review. J Gen Intern Med 2020; 35:954-963. [PMID: 33145687 PMCID: PMC7728943 DOI: 10.1007/s11606-020-06257-4] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 09/18/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Despite evidence that medications to treat opioid use disorder (OUD) are effective, most people who could benefit from this treatment do not receive it. This rapid review synthesizes evidence on current barriers and facilitators to buprenorphine/naloxone and naltrexone at the patient, provider, and system levels to inform future interventions aimed at expanding treatment. METHODS We systematically searched numerous bibliographic databases through May 2020 and selected studies published since 2014. Study selection, data abstraction, coding of barriers and facilitators, and quality assessment were first completed by one reviewer and checked by a second. RESULTS We included 40 studies of buprenorphine (5 also discussed naltrexone). Four types of patient and provider-level barriers to OUD medication use emerged-stigma related to OUD medications, treatment experiences and beliefs (positive or negative), logistical issues (time and costs as well as insurance and regulatory requirements), and knowledge (high or low) of OUD and the role of medications. Stigma was the most common barrier among patients, while logistical issues were the most common barriers among providers. Facilitators for both patients and providers included peer supports. Most administrator-identified or system-level barriers and facilitators fit into the category of logistical issues. We have moderate confidence in buprenorphine findings but low confidence in naltrexone findings due to the small number of studies. DISCUSSION Stigma, treatment experiences, logistical issues, and knowledge gaps are the main barriers associated with low utilization of OUD medications. These barriers can overlap and mutually reinforce each other, but given that, it is plausible that reducing one barrier may lead to reductions in others. The highest priority for future research is to evaluate interventions to reduce stigma. Other priorities for future research include better identification of barriers and facilitators for specific populations, such as those with OUD related to prescription opioids, and for naltrexone use. PROTOCOL REGISTRATION PROSPERO; CRD42019133394.
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26
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Walley AY, Lodi S, Li Y, Bernson D, Babakhanlou-Chase H, Land T, Larochelle MR. Association between mortality rates and medication and residential treatment after in-patient medically managed opioid withdrawal: a cohort analysis. Addiction 2020; 115:1496-1508. [PMID: 32096908 PMCID: PMC7854020 DOI: 10.1111/add.14964] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Revised: 09/16/2019] [Accepted: 01/06/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM Medically managed opioid withdrawal (detox) can increase the risk of subsequent opioid overdose. We assessed the association between mortality following detox and receipt of medications for opioid use disorder (MOUD) and residential treatment after detox. DESIGN Cohort study generated from individually linked public health data sets. SETTING Massachusetts, USA. PARTICIPANTS A total of 30 681 opioid detox patients with 61 819 detox episodes between 2012 and 2014. MEASUREMENTS Treatment categories included no post-detox treatment, MOUD, residential treatment or both MOUD and residential treatment identified at monthly intervals. We classified treatment exposures in two ways: (a) 'on-treatment' included any month where a treatment was received and (b) 'with-discontinuation' individuals were considered exposed through the month following treatment discontinuation. We conducted multivariable Cox proportional hazards analyses and extended Kaplan-Meier estimator cumulative incidence for all-cause and opioid-related mortality for the treatment categories as monthly time-varying exposure variables. FINDINGS Twelve months after detox, 41% received MOUD for a median of 3 months, 35% received residential treatment for a median of 2 months and 13% received both for a median of 5 months. In on-treatment analyses for all-cause mortality compared with no treatment, adjusted hazard ratios (AHR) were 0.34 [95% confidence interval (CI) = 0.27-0.43] for MOUD, 0.63 (95% CI = 0.47-0.84) for residential treatment and 0.11 (95% CI = 0.03-0.43) for both. In with-discontinuation analyses for all-cause mortality, compared with no treatment, AHRs were 0.52 (95% CI = 0.42-0.63) for MOUD, 0.76 (95% CI = 0.59-0.96) for residential treatment and 0.21 (95% CI = 0.08-0.55) for both. Results were similar for opioid-related overdose mortality. CONCLUSIONS Among people who have undergone medically managed opioid withdrawal, receipt of medications for opioid use disorder, residential treatment or the combination of medications for opioid use disorder and residential treatment were associated with substantially reduced mortality compared with no treatment.
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Affiliation(s)
- Alexander Y. Walley
- Boston University School of Medicine-Boston Medical Center, 801 Massachusetts Avenue, Boston, MA 02118,Massachusetts Department of Public Health, 250 Washington Street, Boston, MA 02108
| | - Sara Lodi
- Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA 02118
| | - Yijing Li
- Boston University School of Medicine-Boston Medical Center, 801 Massachusetts Avenue, Boston, MA 02118
| | - Dana Bernson
- Massachusetts Department of Public Health, 250 Washington Street, Boston, MA 02108
| | | | - Thomas Land
- University of Massachusetts Medical School, 55 N Lake Avenue, Worcester, MA 01655
| | - Marc R. Larochelle
- Boston University School of Medicine-Boston Medical Center, 801 Massachusetts Avenue, Boston, MA 02118
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27
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Lee MT, Torres M, Brolin M, Merrick EL, Ritter GA, Panas L, Horgan CM, Lane N, Hopwood JC, De Marco N, Gewirtz A. Impact of recovery support navigators on continuity of care after detoxification. J Subst Abuse Treat 2020; 112:10-16. [DOI: 10.1016/j.jsat.2020.01.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 01/29/2020] [Accepted: 01/30/2020] [Indexed: 11/28/2022]
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Molfenter T, Kim JS, Zehner M. Increasing Engagement in Post-Withdrawal Management Services Through a Practice Bundle and Checklist. J Behav Health Serv Res 2020; 48:400-409. [PMID: 32347425 DOI: 10.1007/s11414-020-09700-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Individuals with substance use disorders (SUDs) who engage in post-withdrawal management (or detoxification) continuing care are more likely to remain drug free or sober and less likely to be incarcerated or die of overdose. Yet, just 21-35% of individuals receiving emergency withdrawal management services receive continuing care. This deficiency is occurring, while overdose rates are high, and limited evidence exists on how to improve this vital transition. To address this gap, withdrawal management service providers employed the LINK Care Transition Implementation System to improve withdrawal management to continuing care transition rates. This system integrates three evidence-based implementation science approaches: (a) practice bundle, (b) process checklist, and (c) standardized organizational change model. This integrated implementation approach improved withdrawal management to continuing care transition rates from 20 (baseline average) to 43% (post-intervention) in (n = 6) Wisconsin withdrawal management centers. This study provides insights into how to improve transitions to enhance SUD care and outcomes.
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Affiliation(s)
- Todd Molfenter
- University of Wisconsin-Madison, 1513 University Avenue, Madison, WI, 53706, USA.
| | - Jee-Seon Kim
- University of Wisconsin-Madison, 1067 Educational Sciences, Madison, WI, 53706-1706, USA
| | - Mark Zehner
- UW Center for Tobacco-Research and Intervention (CTRI), 1930 Monroe Street, Ste. 200, Madison, WI, 53711, USA
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29
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Vakharia RM, Sodhi N, Anis HK, Ehiorobo JO, Mont MA, Roche MW. Patients Who Have Cannabis Use Disorder Have Higher Rates of Venous Thromboemboli, Readmission Rates, and Costs Following Primary Total Knee Arthroplasty. J Arthroplasty 2020; 35:997-1002. [PMID: 31973970 DOI: 10.1016/j.arth.2019.11.035] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Revised: 11/06/2019] [Accepted: 11/22/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Studies have shown that cannabis can interfere with hematological parameters and platelet morphology. The purpose of this study is to investigate whether patients with cannabis use disorder undergoing primary total knee arthroplasty (TKA) have higher rates of (1) venous thromboemboli (VTEs); (2) readmissions; and (3) costs. METHODS Study group patients undergoing primary TKA were identified from a large, nationwide database. Patients who had a history of VTEs, deep vein thromboses (DVTs), pulmonary emboli (PEs), and coagulopathies before their TKA were excluded. Study group patients were matched to controls in a 1:4 ratio by age, sex, a comorbidity index, and medical comorbidities. The query yielded 18,388 patients (cannabis = 3680; controls = 14,708). Outcomes analyzed included rates of 90-day VTEs, DVTs, and PEs, in addition to 90-day readmissions and costs. A P value less than .01 was considered statistically significant. RESULTS Patients who have cannabis use disorder were found to have significantly higher incidence and odds (2.79% vs 1.78%; odds ratio [OR], 1.58; P < .0001) of VTEs, DVTs (2.41% vs 1.44%; OR, 1.68; P < .0001), and PEs (0.97% vs 0.62%; P = .01). Readmissions were significantly higher (27.03% vs 23.18%; OR, 1.22; P < .0001) in patients who have cannabis use disorder. Patients with cannabis use disorder have significantly higher day of surgery ($14,024.88 vs $12,127.49; P < .0001) and 90-day costs ($19,155.45 vs $16,315.00; P < .0001). CONCLUSION This study found that patients who have a cannabis use disorder have higher rates of thromboembolic complications, readmission rates, and costs following primary TKA compared to a matched cohort.
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Affiliation(s)
- Rushabh M Vakharia
- Holy Cross Hospital, Orthopaedic Research Institute, Fort Lauderdale, FL
| | - Nipun Sodhi
- Department of Orthopaedic Surgery, Lenox Hill Hospital, Northwell Health, New York, NY
| | - Hiba K Anis
- Department of Orthopaedic Surgery, Cleveland Clinic Hospital, Cleveland, OH
| | - Joseph O Ehiorobo
- Department of Orthopaedic Surgery, Lenox Hill Hospital, Northwell Health, New York, NY
| | - Michael A Mont
- Department of Orthopaedic Surgery, Lenox Hill Hospital, Northwell Health, New York, NY; Department of Orthopaedic Surgery, Cleveland Clinic Hospital, Cleveland, OH
| | - Martin W Roche
- Holy Cross Hospital, Orthopaedic Research Institute, Fort Lauderdale, FL
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Garnick DW, Horgan CM, Acevedo A, Lee MT, Lee P, Ritter GA, Campbell K. Rural Clients' Continuity Into Follow-Up Substance Use Disorder Treatment: Impacts of Travel Time, Incentives, and Alerts. J Rural Health 2020; 36:196-207. [PMID: 31090968 PMCID: PMC6856385 DOI: 10.1111/jrh.12375] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 03/12/2019] [Accepted: 04/23/2019] [Indexed: 12/17/2022]
Abstract
PURPOSE Treatment after discharge from detoxification or residential treatment is associated with improved outcomes. We examined the influence of travel time on continuity into follow-up treatment and whether financial incentives and weekly alerts have a modifying effect. METHODS For a research intervention during October 2013 to December 2015, detoxification and residential substance use disorder treatment programs in Washington State were randomized into 4 groups: potential financial incentives for meeting performance goals, weekly alerts to providers, both interventions, and control. Travel time was used as both a main effect and interacted with other variables to explore its modifying impact on continuity of care in conjunction with incentives or alerts. Continuity was defined as follow-up care occurring within 14 days of discharge from detoxification or residential treatment programs. Travel time was estimated as driving time from clients' home ZIP Code to treatment agency ZIP Code. FINDINGS Travel times to the original treatment agency were in some cases significant with longer travel times predicting lower likelihood of continuity. For detoxification clients, those with longer travel times (over 91 minutes from their residence) are more likely to have timely continuity. Conversely, residential clients with travel times of more than 1 hour are less likely to have timely continuity. Interventions such as alerts or incentives for performance had some mitigating effects on these results. Travel times to the closest agency for potential further treatment were not significant. CONCLUSIONS Among rural clients discharged from detoxification and residential treatment, travel time can be an important factor in predicting timely continuity.
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Affiliation(s)
- Deborah W. Garnick
- Institute for Behavioral Health, The Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts
| | - Constance M. Horgan
- Institute for Behavioral Health, The Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts
| | - Andrea Acevedo
- Department of Community Health, Tufts University, Medford, Massachusetts
| | - Margaret T. Lee
- Institute for Behavioral Health, The Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts
| | - Panas Lee
- Institute for Behavioral Health, The Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts
| | - Grant A. Ritter
- Institute for Behavioral Health, The Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts
| | - Kevin Campbell
- Research and Data Analysis, Washington State Department of Social and Health Services, Olympia, Washington
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Conner SR, Anderson JR. Are We Acute-Care or Recovery-Oriented? Exploring Ideals and Practices Expressed Within the Substance Use Treatment and Correctional Systems. Subst Use Misuse 2020; 55:2278-2290. [PMID: 32781875 DOI: 10.1080/10826084.2020.1801742] [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] [Indexed: 10/23/2022]
Abstract
The aim of this study was to explore whether treatment and probation professionals describe ideals and practices more aligned with the recovery-oriented systems of care (ROSC) model or the acute-care model. Methods: Semi-structured individual interviews were used to gather qualitative data on the ideals and practices of nine probation professionals and nine treatment professionals. Results: Directed content analysis revealed that all treatment professionals interviewed and eight out of nine probation professionals described more ideals and practices in line with the ROSC model than those in line with the acute-care model. Of all the meaning units coded for model alignment, 81.7% aligned with ROSC and 18.3% with acute care. Of the meaning units coded as ROSC, 51.4% were from treatment professionals and 48.6% from probation professionals. Of the meaning units coded as acute care, 30.2% came from treatment professionals and 69.8% from probation professionals. In building a ROSC, it seems the concern is less about buy in for recovery-oriented characteristics and more about shedding characteristics of the acute-care model. Although professionals have many ideals and practices in line with the ROSC model, some acute-care characteristics linger and could continue to exist without intervention.
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Affiliation(s)
- Stacy R Conner
- Family and Human Services Department, Washburn University, Topeka, Kansas, USA
| | - Jared R Anderson
- School of Family Studies and Human Services, Kansas State University, Manhattan, Kansas, USA
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Peterson C, Liu Y, Xu L, Nataraj N, Zhang K, Mikosz CA. U.S. National 90-Day Readmissions After Opioid Overdose Discharge. Am J Prev Med 2019; 56:875-881. [PMID: 31003811 PMCID: PMC6527476 DOI: 10.1016/j.amepre.2018.12.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 12/14/2018] [Accepted: 12/17/2018] [Indexed: 01/04/2023]
Abstract
INTRODUCTION U.S. hospital discharges for opioid overdose increased substantially during the past two decades. This brief report describes 90-day readmissions among patients discharged from inpatient stays for opioid overdose. METHODS In 2018, survey-weighted analysis of hospital stays in the 2016 Healthcare Cost and Utilization Project National Readmissions Database yielded the national estimated proportion of patients with opioid overdose stays that had all-cause readmissions within ≤90 days. A multivariable logistic regression model assessed index stay factors associated with readmission by type (opioid overdose or not). Number of readmissions per patient was assessed. RESULTS More than 24% (n=14,351/58,850) of patients with non-fatal index stays for opioid overdose had at least one all-cause readmission ≤90 days of index stay discharge and 3% (n=1,658/58,850) of patients had at least one opioid overdose readmission. Less than 0.2% (n=104/58,850) of patients had more than one readmission for opioid overdose. Patient demographic characteristics (e.g., male, older age), comorbidities diagnosed during the index stay (e.g., drug use disorder, chronic pulmonary disease, psychoses), and other index stay factors (Medicare or Medicaid primary payer, discharge against medical advice) were significantly associated with both opioid overdose and non-opioid overdose readmissions. Nearly 30% of index stays for opioid overdose included heroin, which was significantly associated with opioid overdose readmissions. CONCLUSIONS A quarter of opioid overdose patients have ≤90 days all-cause readmissions, although opioid overdose readmission is uncommon. Effective strategies to reduce readmissions will address substance use disorder as well as comorbid physical and mental health conditions.
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Affiliation(s)
- Cora Peterson
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia.
| | - Yang Liu
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Likang Xu
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Nisha Nataraj
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Kun Zhang
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Christina A Mikosz
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
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Miles J. Changes in Residential Substance Use Treatment Service Access Resulting From Recent Medicaid Section 1115 Waivers. Psychiatr Serv 2019; 70:428-431. [PMID: 30755128 PMCID: PMC6494678 DOI: 10.1176/appi.ps.201800543] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Medicaid stands to play a significant role in addressing the needs of individuals with a substance use disorder; however, many state Medicaid programs do not cover a full continuum of care. A growing number of states are taking advantage of Section 1115 demonstration waivers to augment their covered benefits, including experimenting with financing residential treatment services that previously were not eligible for reimbursement. Concerns over potential overuse of these services or increased spending due to this service expansion may be tempered by complementary delivery system transformation focused on reining in costs and improving care quality.
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Affiliation(s)
- Jennifer Miles
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts. Steven S. Sharfstein, M.D., Haiden A. Huskamp, Ph.D., and Alison Evans Cuellar, Ph.D., are editors of this column
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Zhu H, Wu LT. National trends and characteristics of inpatient detoxification for drug use disorders in the United States. BMC Public Health 2018; 18:1073. [PMID: 30157815 PMCID: PMC6114033 DOI: 10.1186/s12889-018-5982-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 08/21/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Prior studies indicate that the opportunity from detoxification to engage in subsequent drug use disorder (DUD) treatment may be missed. This study examined national trends and characteristics of inpatient detoxification for DUDs and explored factors associated with receiving DUD treatment (i.e., inpatient drug detoxification plus rehabilitation) and discharges against medical advice (DAMA). METHODS We analyzed inpatient hospitalization data involving the drug detoxification procedure for patients aged≥12 years (n = 271,403) in the 2003-2011 Nationwide Inpatient Samples. We compared the estimated rate and characteristics of inpatient drug-detoxification hospitalizations between 2003 and 2011 and determined demographic and clinical correlates of inpatient drug detoxification plus rehabilitation (versus detoxification-only) and DAMA (versus transfer to further treatment). RESULTS There was no significant yearly change in the population rate of inpatient drug-detoxification hospitalizations during 2003-2011. The majority of inpatient drug detoxification were patients aged 35-64 years, males, and those on Medicaid. Among inpatient drug-detoxification hospitalizations, only 13% received detoxification plus rehabilitation during inpatient care, and up to 14% were DAMA; the most commonly identified diagnoses were opioid use disorder (OUD; 75%) and non-addiction mental health disorders (48%). Being on Medicaid (vs. having private insurance) and having OUD (vs. no OUD) were associated with decreased odds of receiving detoxification plus rehabilitation, as well as increased odds of DAMA. CONCLUSIONS These findings suggest the presence of a potentially large detoxification-treatment gap for inpatient detoxification patients. They highlight the need for implementing DUD services to improve engagement in receiving further DUD treatment in order to improve recovery and health outcomes.
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Affiliation(s)
- He Zhu
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Duke University Medical Center, BOX 3903, Durham, NC, 27710, USA.
| | - Li-Tzy Wu
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Duke University Medical Center, BOX 3903, Durham, NC, 27710, USA.
- Department of Medicine, Division of General Internal Medicine, Duke University Medical Center, Durham, NC, USA.
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA.
- Center for Child and Family Policy, Sanford School of Public Policy, Duke University, Durham, NC, USA.
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