What will it take? Using an implementation research framework to identify facilitators and barriers in implementing a school-based referral system for sexual health services.

BACKGROUND: Across the United States, sexually transmitted infections and unintended pregnancy rates are alarmingly high among youth. Schools, due to their proximity and access to youth, can increase student access to sexual health services (SHS) by creating referral systems (RS) to link students to school- and community-based SHS. From 2013 to 2018, the Centers for Disease Control and Prevention's Division of Adolescent and School Health funded 17 Local Education Agencies (LEA) to partner with priority schools and stakeholders to develop and implement RS to increase student access to SHS. Cicatelli Associates Inc. (CAI) was funded to provide capacity-building to LEA. In 2016-2017, CAI conducted case studies at two LEA, both large and urban sites, but representing different geographical and political contexts, to elucidate factors that influence RS implementation. METHODS: Nineteen LEA and community-based healthcare (CBH) staff were interviewed in the Southeastern (n = 9) and Western U.S. (n = 10). Key constructs (e.g., leadership engagement, resources, state and district policies) across the five domains of the Consolidated Framework for Implementation Research (CFIR) framework guided the methodology and analysis. Qualitative data was analyzed using the Framework Method and contextual factors and themes that led to RS implementation were identified. RESULTS: Interviewees strongly believed that school-based RS can decrease STI, HIV and unintended pregnancy and increase students' educational attainment. We identified the following contextual key factors that facilitate successful implementation and integration of an RS: enforcing state and district policies, strong LEA and CBH collaboration, positive school culture towards adolescent health, knowledgeable and supportive staff, leveraging of existing resources and staffing structures, and influential district and school building-level leadership and champions. Notably, this case study challenged our initial assumptions that RS are easily implemented in states with comprehensive SHS policies. Rather, our conversations revealed how districts and local-level policies can have significant impact and influence to impede or promote those policies. CONCLUSIONS: Through the use of the CFIR framework, the interviews identified important contextual factors and themes associated with LEAs' implementation barriers and facilitators. The study's results present key recommendations that other LEA can consider to optimize integration of RS-related evidence-based practices, systems, and policies in their districts.

"It's Really Overwhelming": Patient Perspectives on Care Coordination.

PURPOSE: Failures of care coordination among health care providers are known to lead to poorer health outcomes for patients with complex medical needs. However, there has been limited research into the perspectives of patients who receive care from a variety of health care providers. This qualitative study sought to characterize the factors leading to emergency department (ED) patient satisfaction and dissatisfaction with their care coordination. METHODS: Semistructured telephone interviews were conducted with 25 adult patients following ED visits about their experiences with their care coordination. All patients interviewed had 2 or more ED visits and hospitalizations in the past year and/or health providers in more than one health system. Interview transcripts were coded and analyzed following a modified grounded theory approach. RESULTS: Four broad categories of themes emerged from the patient interviews covering the following: (1) perceptions of care coordination between their providers, (2) the role of electronic health records, (3) challenges with information exchange between health systems, and (4) sources of support for care coordination activities, emphasizing the important role of the primary care provider. CONCLUSIONS: Patients with multiple health care providers identified significant barriers to communication among providers and inadequate support with care coordination activities. Expansion of team-based models of primary care and prioritizing interoperable technology for sharing patient health information between providers will be critical to improving the patient experience and the safety of transitions of care.

What Factors Affect Physicians' Decisions to Prescribe Opioids in Emergency Departments?

Objective: With 42% of all emergency department visits in the United States related to pain, physicians who work in this setting are tasked with providing adequate pain management to patients with varying primary complaints and medical histories. Complicating this, the United States is in the midst of an opioid overdose epidemic. State governments and national organizations have developed guidelines and legislation to curtail opioid prescriptions in acute care settings, while also incentivizing providers for patient satisfaction and completeness of pain control. In order to inform future policies that focus on provider pain medication prescribing, we sought to characterize the factors physicians weigh when considering treating pain with opioids in the emergency department. Methods: We conducted and transcribed open-ended, semistructured qualitative interviews with 52 physicians at a national emergency medicine conference. Results: Participants reported a wide range of factors contributing to their opioid prescribing patterns related to three domains: 1) provider assessment of pain characteristics, 2) patient-based considerations, and 3) practice environment. Pain characteristics include the characteristics of various acute and chronic pain syndromes, including physicians' empathy due to their own experiences with pain. Patient characteristics include "trustworthiness," race and ethnicity, and the concern for risk of misuse. Factors related to the practice environment include hospital policy, legislation/regulation, and guidelines. Conclusion: The decision to prescribe opioids to patients in the emergency department is complex and nuanced. Physicians are interested in guidance and are concerned about the competing pressures placed on their opioid prescribing due to incentives related to patient satisfaction scores on one hand and inflexible policies that do not allow for individualized, patient-centered decisions on the other.

Adolescent Cellphone Use While Driving: An Overview of the Literature and Promising Future Directions for Prevention.

Motor vehicle crashes are the leading cause of death in adolescents, and drivers aged 16-19 are the most likely to die in distracted driving crashes. This paper provides an overview of the literature on adolescent cellphone use while driving, focusing on the crash risk, incidence, risk factors for engagement, and the effectiveness of current mitigation strategies. We conclude by discussing promising future approaches to prevent crashes related to cellphone use in adolescents. Handheld manipulation of the phone while driving has been shown to have a 3 to 4-fold increased risk of a near crash or crash, and eye glance duration greater than 2 seconds increases crash risk exponentially. Nearly half of U.S. high school students admit to texting while driving in the last month, but the frequency of use according to vehicle speed and high-risk situations remains unknown. Several risk factors are associated with cell phone use while driving including: parental cellphone use while driving, social norms for quick responses to text messages, and higher levels of temporal discounting. Given the limited effectiveness of current mitigation strategies such as educational campaigns and legal bans, a multi-pronged behavioral and technological approach addressing the above risk factors will be necessary to reduce this dangerous behavior in adolescents.

Unused opioid analgesics and drug disposal following outpatient dental surgery: A randomized controlled trial.

BACKGROUND: Individuals who abuse prescription opioids often use leftover pills that were prescribed for friends or family members. Dental surgery has been identified as a common source of opioid prescriptions. We measured rates of used and unused opioids after dental surgery for a pilot program to promote safe drug disposal. METHODS: We conducted a randomized controlled trial of opioid use patterns among patients undergoing surgical tooth extraction at a university-affiliated oral surgery practice. The primary objective was to describe opioid prescribing and consumption patterns, with the number of unused opioid pills remaining on postoperative day 21 serving as the primary outcome. The secondary aim was to measure the effect of a behavioral intervention (informing patients of a pharmacy-based opioid disposal program) on the proportion of patients who disposed or reported intent to dispose of unused opioids. (NCT02814305) Results: We enrolled 79 patients, of whom 72 filled opioid prescriptions. On average, patients received 28 opioid pills and had 15 pills (54%) left over, for a total of 1010 unused pills among the cohort. The behavioral intervention was associated with a 22% absolute increase in the proportion of patients who disposed or reported intent to dispose of unused opioids (Fisher's exact p=0.11). CONCLUSION: Fifty-four percent of opioids prescribed in this pilot study were not used. The pharmacy-based drug disposal intervention showed a robust effect size but did not achieve statistical significance. Dentists and oral surgeons could potentially reduce opioid diversion by moderately reducing the quantity of opioid analgesics prescribed after surgery.