A mixed-method comparison of physician-reported beliefs about and barriers to treatment with medications for opioid use disorder

BACKGROUND

Evidence demonstrates that medications for treating opioid use disorder (MOUD) -namely buprenorphine, methadone, and extended-release naltrexone-are effective at treating opioid use disorder (OUD) and reducing associated harms. However, MOUDs are heavily underutilized, largely due to the under-supply of providers trained and willing to prescribe the medications.

METHODS

To understand comparative beliefs about MOUD and barriers to MOUD, we conducted a mixed-methods study that involved focus group interviews and an online survey disseminated to a random group of licensed U.S. physicians, which oversampled physicians with a preexisting waiver to prescribe buprenorphine. Focus group results were analyzed using thematic analysis. Survey results were analyzed using descriptive and inferential statistical methods.

RESULTS

Study findings suggest that physicians have higher perceptions of efficacy for methadone and buprenorphine than for extended-release naltrexone, including for patients with co-occurring mental health disorders. Insurance obstacles, such as prior authorization requirements, were the most commonly cited barrier to prescribing buprenorphine and extended-release naltrexone. Regulatory barriers, such as the training required to obtain a federal waiver to prescribe buprenorphine, were not considered significant barriers by many physicians to prescribing buprenorphine and naltrexone in office-based settings. Nor did physicians perceive diversion to be a prominent barrier to prescribing buprenorphine. In focus groups, physicians identified financial, logistical, and workforce barriers-such as a lack of addiction treatment specialists-as additional barriers to prescribing medications to treat OUD.

CONCLUSIONS

Additional education is needed for physicians regarding the comparative efficacy of different OUD medications. Governmental policies should mandate full insurance coverage of and prohibit prior authorization requirements for OUD medications.

The inter- and intrarater reliability and agreement for field-based assessment of scapular control, shoulder range of motion, and shoulder isometric strength in elite adolescent athletes

OBJECTIVES

To investigate the intra- and interrater reliability and agreement for field-based assessment of scapular control, shoulder range of motion (ROM), and shoulder isometric strength in elite youth athletes.

DESIGN

Test-retest reliability and agreement study.

SETTING

Eight blinded raters (two for each assessment) assessed players on field during two testing sessions separated by one week.

PARTICIPANTS

162 elite youth handball players with or without a history of previous shoulder pain within the preceding six months.

MAIN OUTCOME MEASURES

Kappa (κ) and prevalence-adjusted bias-adjusted kappa (PABAK) coefficients for scapular control reliability, and 95% limits of agreement (LOA) for ROM and strength agreement.

RESULTS

Scapular control demonstrated substantial to almost perfect reliability (κ 0.67 to 0.84, PABAK from 0.68 to 0.88). Mean strength values ranged from 0.9 N/kg to 1.6 N/kg, and LOAs ranged from -0.7 N/kg to 0.8 N/kg. Rotational strength revealed additionally systematic bias between and within rater. No or acceptable systematic bias were evident for ROM and abduction strength measures. Mean values and LOAs for ROM ranged between 39.9° to 52.3°, and from -12.6° to 9.9°, respectively.

CONCLUSIONS

Scapular control and ROM can be assessed on the field with acceptable reliability. The threshold for reliable measurements of isometric strength using handheld-dynamometers is high.

The SMS, Phone, and medical Examination sports injury surveillance system is a feasible and valid approach to measuring handball exposure, injury occurrence, and consequences in elite youth sport

Current methods of sports injury surveillance are limited by lack of medical validation of self-reported injuries and/or incomplete information about injury consequences beyond time loss from sport. The aims of this study were to (a) evaluate the feasibility of the SMS, Phone, and medical Examination injury surveillance (SPEx) system (b) to evaluate the proportion of injuries and injury consequences reported by SPEx when compared to outcomes from a modified version of the Oslo Sports Trauma Research Centre (OSTRC) Overuse Injury Questionnaire. We followed 679 elite adolescent handball players over 31 weeks using the SPEx system. During the last 7 weeks, we also implemented a modified OSTRC questionnaire in a subgroup of 271 players via telephone interviews. The weekly response proportions to the primary SPEx questions ranged from 85% to 96% (mean 92%). SMS responses were received from 79% of the participants within 1 day. 95% of reported injuries were classified through the telephone interview within a week, and 67% were diagnosed by medical personnel. Comparisons between reported injuries from SPEx and OSTRC demonstrated fair (κ = 39.5% [25.1%-54.0%]) to substantial prevalence-adjusted bias-adjusted kappa (PABAK = 66.8% [95% CI 58.0%-75.6%]) agreement. The average injury severity score difference between SPEx and the OSTRC approach was -0.2 (95% CI -3.69-3.29) of possible 100 with 95% limits of agreement from(-14.81-14.41). These results support the feasibility and validity of the SPEx injury surveillance system in elite youth sport. Future studies should evaluate the external validity of SPEx system in different cohorts of athletes.

Validity of the SMS, Phone, and medical staff Examination sports injury surveillance system for time-loss and medical attention injuries in sports

The accurate measurement of sport exposure time and injury occurrence is key to effective injury prevention and management. Current measures are limited by their inability to identify all types of sport-related injury, narrow scope of injury information, or lack the perspective of the injured athlete. The aims of the study were to evaluate the proportion of injuries and the agreement between sport exposures reported by the SMS messaging and follow-up telephone part of the SMS, Phone, and medical staff Examination (SPEx) sports injury surveillance system when compared to measures obtained by trained on-field observers and medical staff (comparison method). We followed 24 elite adolescent handball players over 12 consecutive weeks. Eighty-six injury registrations were obtained by the SPEx and comparison methods. Of them, 35 injury registrations (41%) were captured by SPEx only, 10 injury registrations (12%) by the comparison method only, and 41 injury registrations (48%) by both methods. Weekly exposure time differences (95% limits of agreement) between SPEx and the comparison method ranged from -4.2 to 6.3 hours (training) and -1.5 to 1.0 hours (match) with systematic differences being 1.1 hours (95% CI 0.7 to 1.4) and -0.2 (95% CI -0.3 to -0.2), respectively. These results support the ability of the SPEx system to measure training and match exposures and injury occurrence among young athletes. High weekly response proportions (mean 83%) indicate that SMS messaging can be used for player measures of injury consequences beyond time-loss from sport. However, this needs to be further evaluated in large-scale studies.

Soluble CD36 (sCD36) clusters with markers of insulin resistance, and high sCD36 is associated with increased type 2 diabetes risk

CONTEXT AND OBJECTIVE

Soluble CD36 (sCD36) may be an early marker of insulin resistance and atherosclerosis. The objective of this prospective study was to evaluate sCD36 as a predictor of type 2 diabetes and to study its relationship with components of the metabolic syndrome (MetSy). DESIGN, SETTING, PARTICIPANTS, AND OUTCOME MEASURES: We conducted a case-referent study nested within a population-based health survey. Baseline variables included sCD36, body mass index, blood pressure, blood lipids, adipokines, inflammatory markers, and beta-cell function. A total of 173 initially nondiabetic cohort members who developed type 2 diabetes during 10 yr of follow-up were matched (1:2) with referents. Exploratory factor analysis was applied to hypothesize affiliation of sCD36 to the MetSy components.

RESULTS

Doubling of baseline sCD36 increases the odds ratio for diabetes development by 1.24 in the general study population and by 1.45 in the female population (P < 0.025). Comparing upper sCD36 quartiles with lower, odds ratio for diabetes was 4.6 in women (P = 0.001), 3.15 in men (P = 0.011), and 2.6 in obese individuals (P < 0.025). Multivariate analysis shows that sCD36 does not predict diabetes independent of fasting plasma glucose and insulin. Factor analysis of 15 variables generates a six-factor model explaining 66-69% of total variance, where sCD36, body mass index, insulin, proinsulin, and leptin were assigned to the obesity/insulin resistance cluster.

CONCLUSIONS

Upper quartile sCD36 is associated with elevated diabetes risk independent of age, gender, and obesity. Baseline sCD36 does not, however, predict diabetes independent of fasting glucose and insulin. sCD36 clusters with important markers of insulin resistance and MetSy that are key predictors of type 2 diabetes.

Respiratory effects of experimental exposure to office dust

The aim of this experiment was to test if healthy persons respond to exposures to normal office dust with objective or subjective effects in a dose-related way. If they did, the importance of their personal characteristics should be investigated. This paper presents the results related to respiratory effects caused by exposures to office dust. The experiment compared the responses of 24 healthy non-sensitive adult subjects with no known hyperreactivity to exposure to normal office dust in the air at 136 and 390 microg/m3 with their responses in clean air. The exposure duration was 5.25 h in a climate chamber under controlled conditions. The dust had no major identifiable specific reactive compounds. There were no direct effects of dust exposures on nasal lavages or rhinometry. The overall indications of the experiment are that healthy subjects without any hypersensitive reactions seem to respond to exposure to house dust without specific reactive components. The only effect indicated was on eosinophil cationic protein in nasal lavages and peak flow. A delayed effect on peak expiratory flow was observed the day after the exposure. Other effects were seen but in opposite direction of expectations. Several deviations from the original design of the experiment prevent any definitive conclusions from being made from these findings before they have been confirmed in future experiments to come.

PRACTICAL IMPLICATIONS

Reflecting the exploratory status of the study its major implication is to point at possible future hypotheses. The study implies that office dust may have an effect on occupants' lung function even at concentrations found in normal indoor environments. The influences of a multitude of response modifying variables were tested but no consistent pattern was found. The study does therefore not identify a specific risk group but suggests that among normal non-sensitized subjects most of the traditional risk factors can be rejected as single responsible risk factor.

Inaccuracy of international normalized ratio (INR) measurements and suggestions for improved WHO guidelines for calibration of reference preparations--a statistical study

Numerous empirical studies show that the accuracy of international normalized ratio (INR) measurements is unsatisfactory and worse than generally expected. We demonstrate that a plausible reason for this large inaccuracy is a conventional calibration procedure of reference preparations with (i) an erroneous assumption that the line relating logarithmic prothrombin times (log PTs) of patients passes through the mean log PT of the 'normal' population (mean normal PT); (ii) non-perceived interactions between patients and PT systems; and (iii) systematic exclusions of 'outliers'. The same conventional procedure also results in serious overestimation of the accuracy of INR measurements, thus leading to a false sense of security in oral anticoagulant therapy. In an example with data from WHO guidelines, we show that the systematic overprediction of INR (which is believed to be 0) may be as large as 5%, when prediction is performed under the conventional WHO model. Under the same model the CV of the predicted vs. the true INR is believed to be only about 1% when it in reality is more than 4%. We suggest that the conventional calibration procedure is modified in order to reduce the twofold negative impact of lower true accuracy and overestimated reported accuracy on oral anticoagulant therapy and to allow for an unambiguous definition of true INR values.

Effects in the eyes caused by exposure to office dust

This Danish Office Dust Experiment compares the responses of 24 normal non-sensitive adult subjects to exposure to normal office dust in the air at 136 and 390 micrograms/m3 (median) and to their responses in clean air. The exposure duration was 5 1/4 h in a climate chamber under controlled conditions. The dust had no major identifiable specific reactive compounds. The overall conclusion is that healthy subjects without any hypersensitive reactions seem to respond to exposure to the house dust. The effects observed were all found in interaction with response modifying factors. The effects were a decrease in inflammatory cells in tear fluids, increased epithelium defects, and a decrease in break-up time. No effect was seen on eye reddening, or eye sensitivity to CO2. As no specific hypotheses could be specified before the study for the observed interactions, no definitive conclusions can be made. Furthermore, it seemed that there was no consistency in the interacting factors after the exposure and the next morning. A tentative analysis of the effects of the importance of personal characteristics showed that only a minority within the subject group may respond to the exposure. However, no common set of sensitivity measures could be defined for these responders.

Self-management of oral anticoagulation in children with congenital heart disease

OBJECTIVE

The concept of self-management of oral anticoagulation has been shown to entail better quality of treatment than conventional management when assessed in selected adults. We have extended the concept of self-management to include children with congenital cardiac disease, hypothesizing self-management of oral anticoagulation is also possible in this subset of patients. Our aim was to assess the quality of self-management.

METHODS

We trained 14 children aged from 2.2 to 15.6 years, with a mean age of 9.7 years, and their parents, in domiciliary analysis of the International Normalized Ratio and necessary adjustment of dosage of coumarin. The curriculum for training lasted for 27 weeks, and the patients and their parents were followed for a period of up to 31 months by weekly measurement of the values obtained for the International Normalized Ratio.

RESULTS

The patients were observed over a mean of 547 days, with a range from 214 to 953 days. The patients were within the therapeutic targetted range of the International Normalized Ratio for a median of 65.5% of the time, with a range from 17.6% to 90.4%. None of the patients experienced thromboembolic or bleeding complications requiring doctoral intervention. All the patients and their parents expressed full satisfaction with the treatment.

CONCLUSION

Self-management of oral anticoagulation provides a good quality of treatment, which is feasible and safe in selected children with congenital cardiac disease.

Self-management of oral anticoagulant therapy for mechanical heart valve patients

OBJECTIVE

Self-management of oral anticoagulant therapy (OAT) has shown good results on a short-term basis. We hypothesize that self-management of OAT provides a better quality of treatment than conventional management also on a long-term basis. The aim of this study was to assess the quality of self-management of OAT in patients with mechanical heart valve prostheses on a 4-year perspective in a prospective, non-randomized study.

DESIGN

Twenty-four patients with mechanical heart valves and on self-managed OAT were followed for up to 4 years. A matched, retrospectively selected group of conventionally managed heart valve patients (control group) was used as reference.

RESULTS

The median observation time was 1175 days (range: 174-1428 days). The self-managed patients were within therapeutic INR target range for a mean of 78.0% (range: 36.1%-93.9%) of the time compared with 61.0% (range 37.4%-2.9%) for the control group.

CONCLUSION

Self-management of OAT is a feasible and safe concept for selected patients with mechanical heart valve prostheses also on a long-term basis. It provides at least as good and most likely better quality of anticoagulant therapy than conventional management assessed by time within the therapeutic International Normalized Ratio (INR) target range.

[Self management of peroral anticoagulant therapy in patients with artificial heart valves]

Twenty-one heart valve operated patients (age 19-70 years) were trained in self-managed oral anticoagulant therapy using a home coagulometer (CoaguChek). Twenty patients accomplished between eight and 29 (median 24) months of self management and were fully capable of self management after 30 weeks of training. No patients experienced major bleeds or thrombo-embolic events. A control group of 20 patients from our department was matched, retrospectively, to the study group. The self-managing patients were within the therapeutic INR range 78% of the study period compared to 54% for the control patients. All self-managing patients had their median INR-value within the therapeutic range, versus only 14 in the control group. Self-management of oral anticoagulant therapy seems feasible for selected patients.

Self management of oral anticoagulant therapy after heart valve replacement

OBJECTIVE

Patients with mechanical heart valves require lifelong oral anticoagulant treatment which entails frequent blood sampling and dosage adjustment. The purpose of this study was to investigate the feasibility of letting heart valve operated patients manage blood specimen analysis and dosage adjustment themselves.

METHODS

A total of 21 patients were enrolled in the study and followed for at least 9 months postoperatively. Immediately after the heart valve operation they were trained in operating a CoaguChek international normal ratio (INR) monitor to analyze capillary whole blood samples. Subsequently training in dosage adjustment was accomplished and all patients were considered fully capable of self management after 30 weeks. In the training period, parallel laboratory INR measurements were made at 3-4 week intervals for reference. A control group of 20 patients was matched, respectively, to the study group. The INR target range was 2.0-3.0.

RESULTS

Out of the 21 study patients 19 continued self management beyond 9 months. The median INR value obtained with the monitor was within therapeutic target range for all study patients and only 15 out of 20 control patients were within this range. The mean systematic deviation between laboratory and CoaguChek INR was 7.8% but each patient had a constant characteristic deviation from -11 to +21%. The study patients were within therapeutic target range 77% of the time compared with 53% for the control patients.

CONCLUSIONS

Self management of oral anticoagulation is feasible for selected patients and constitutes a significant service improvement compared with conventional management. The CoaguChek monitor seems sufficiently accurate and reliable for self testing and the treatment quality is comparable or even better than conventional management. Assessment of the rate of bleeding and thrombo-embolic events shall be settled in studies comprising larger number of patients.

Practicability of patient self-testing of oral anticoagulant therapy by the international normalized ratio (INR) using a portable whole blood monitor. A pilot investigation

The prophylactic efficacy of long-term oral anticoagulant treatment (OAT) has been demonstrated in a number of clinical conditions with increased tendency to thromboembolism, and the number of individuals subjected to OAT in the industrialised world has increased substantially in recent years. Since this therapy requires considerable resources from both the health care system and the patients, the feasibility of patients' self-monitoring and self-management of OAT has been investigated (1,2,3). The anticipated advantages of this approach include improved convenience and compliance for the patient, who may increase his apprehension for managing the treatment. In addition, self-testing allows for more frequent control compared to the conventional out-patient approach. Importantly, a prerequisite for conceiving a safe and operational concept for patient self-management (PSM) is the availability of a portable INR monitoring system with an accuracy, precision, reproducibility, and long-term reliability comparable to standard coagulometric equipment. The purpose of the present study was to evaluate the feasibility of a commercially available INR-monitor. CoaguChek, for patient self-testing, through a step-wise investigation of the performance characteristics of the equipment in the laboratory, in command of the patient, and during self-testing and self-adjustment of treatment at home. Laboratory INR values were used as reference.