Opioid Prescribing in Rural Family Practices: A Qualitative Study.

BACKGROUND: Rural Tennessee, especially rural East Tennessee has seen a dramatic increase in rates of controlled drug prescriptions and controlled drug overdose deaths in recent years. However, little is known about the individual decisions to prescribe or continue prescriptions with relation to addiction concerns. OBJECTIVES: The purpose of this study was to learn more about what factors lead to physicians' prescribing control drugs for non-cancer pain through the use of focus groups. METHODS: A qualitative study, using focus groups, in five family medicine clinics in East Tennessee and Southwest Virginia. The investigators used a semi-structured interview guide designed to facilitate group discussions about prescription drug abuse and misuse. RESULTS: There were four main themes identified by the focus groups: (1) prescribers' changing prescribing patterns over time; (2) factors that influence controlled drug prescribing; (3) use and barriers to using state prescription drug monitoring programs (PDMPs); (4) prescribing controlled drugs to women of childbearing age. Each theme had several subthemes. CONCLUSIONS: The balance between treating the patient's symptoms and causing potential harm is a challenge. The patient's pain cannot be ignored, but the potential harm of opioid therapy is not taken lightly. As the public health concern of prescription drug abuse in rural Appalachia continues to spread, prescribers are aware of their connection to the problem, and ultimately the solution.

Transgender health education for medical students.

BACKGROUND: Transgender individuals face numerous health disparities and report negative experiences with health care providers related to their gender identity. Significant gaps in medical education regarding transgender health persist despite calls for increased sexual and gender minority content. The purpose of this student-led study was to assess the effectiveness of a half-day educational intervention on first- and second-year medical students' attitudes and knowledge of transgender health. METHODS: Students and faculty members collaborated to develop an educational session on transgender health. This content was presented to first- and second-year medical students at Integrated Grand Rounds, a pedagogical method in which basic science and clinical faculty members co-present didactic content interspersed between live patient interviews and student-led small group discussions. Student participants (n = 138) completed voluntary 9-item pre- and post-session surveys assessing comfort with and knowledge of transgender medicine. RESULTS: Students' comfort with and perceived knowledge about transgender patients increased significantly between pre- and post-test. Students' knowledge of transgender medicine standards of care also improved, though not all items reached significance. DISCUSSION: A half-day educational intervention improved many facets of medical students' attitudes and knowledge about transgender patients. The significant disparities in physical health, mental health and access to care currently experienced by transgender persons in the United States warrants the continued testing and refinement of educational interventions for future and practising providers. Students' comfort with transgender patients increased significantly between pre- and post-test.

Relationship of Patient Self-Administered COPD Assessment Test to Physician Standard Assessment of Chronic Obstructive Pulmonary Disease in a Family Medicine Residency Training Program.

Assessing the global impact of chronic obstructive pulmonary disease (COPD) on a patient's life can be difficult to perform in the clinical setting due to time constraints and workflow challenges. The primary objective of this study was to compare disease impact ratings between patient self-administered COPD Assessment Test (CAT) and physician standard office assessment. This prospective study was conducted at a family medicine residency clinic in northeast Tennessee. The study included two study groups: 1) adult patients seen at the clinic during the 3-month study period with an active diagnosis of COPD, and 2) their physicians. Physicians' assessment of the impact of COPD on their patients' daily lives was compared to patients' self-administered CAT assessments. Physician assessment of COPD impact and patient assessment of CAT categories significantly differed (χ2=11.0, P=0.012). There was very poor agreement between patient and physician ratings (κ=0.003), with 42.9% of physician ratings underestimating the impact, 28.6% overestimating the impact, and 28.6% correctly estimating the impact COPD had on their patients' lives. These findings support the use of validated assessment tools to help providers understand the symptom burden for patients with COPD.

Pharmacists' and prescribers' neonatal abstinence syndrome (NAS) prevention behaviors: a preliminary analysis.

Background Maternal opioid use and neonatal abstinence syndrome (NAS) incidence have increased markedly in the US in recent years. Objectives (1) To assess prescribers' and community pharmacists' guideline-based NAS prevention behaviors; (2) to describe providers' perceptions of contraceptive appropriateness in female patients of childbearing age. Method Cross-sectional study of 100 randomly selected primary care physicians, 100 prescribers authorized to engage in in-office treatment of opioid use disorders with buprenorphine, 100 pain management clinic directors, and 100 community pharmacists in Tennessee (N = 400 providers total) to evaluate self-reported engagement in 15 NAS prevention behaviors and perceived appropriateness of 8 contraceptive methods in opioid using women of childbearing age. Results An overall response rate of 17.5% was obtained. Pain clinic directors reported the most engagement in NAS prevention, engaging 80% or more of female patients of childbearing age prescribed an opioid in 11 prevention behaviors, followed by buprenorphine prescribers (8 behaviors), primary care physicians (5 behaviors), and community pharmacists (2 behaviors). Pain clinic directors, primary care physicians, and community pharmacists perceived oral contraceptive pills and patches to be as appropriate as long-acting, reversible forms of contraception (e.g., implants, injectable depots, intrauterine devices). Conclusion Provider engagement in behaviors that could prevent NAS is variable. Interventions should be implemented that equip providers to engage patients in conversations about long-acting, reversible contraception.

The effects of eticlopride on Morris water task performance in male and female rats neonatally treated with quinpirole.

RATIONALE: Previous studies have shown that neonatal quinpirole treatment which results in long-term dopamine D2 receptor supersensitization (D2 receptor priming) produces cognitive deficits in preweanling and adult rats behaviorally tested on the Morris water task (MWT). OBJECTIVE: This study was designed to analyze whether pretraining administration of the D2 antagonist eticlopride alleviates cognitive deficits produced by neonatal quinpirole treatment. METHODS: Both male and female Sprague-Dawley rats were treated with quinpirole HCl (1 mg/kg) or saline from postnatal days 1 to 21. From P22 to P24, rats were tested on the place version of the MWT in which a hidden platform remains stationary throughout training. From P25 to P28, rats were tested on the match-to-place version of the MWT, and rats are given a pair of daily training trials to locate the hidden platform that was moved to a new location each day. Fifteen minutes before each training session, rats were intraperitoneally administered with eticlopride (0.01 or 0.02 mg/kg) or saline. RESULTS: Pretraining eticlopride treatment alleviated cognitive deficits produced by neonatal quinpirole treatment in both male and female rats on the place version of the MWT, as well as in males tested on the match-to-place version of the MWT. However, there were no significant deficits produced by neonatal quinpirole treatment in females tested on the match-to-place version of the MWT, and control males demonstrated superiority over control females on this version of the task. CONCLUSIONS: Pretraining administration of the dopamine D2 antagonist eticlopride alleviated cognitive deficits produced by neonatal quinpirole treatment. However, it appears that the dopamine D2 receptor may have a more important influence on cognitive performance in males than in females, which may be related to increased sensitivity of the D2 receptor in males.

Evaluation of a quality improvement curriculum for family medicine residents.

BACKGROUND AND OBJECTIVES: East Tennessee State University's (ETSU) Department of Family Medicine initiated Quality Improvement (QI) training in its three residency programs in 2008. The purpose of the project was to develop, implement, and assess a formal curriculum and experiential learning process to train family medicine residents in QI knowledge and skills. METHODS: Family medicine faculty members received training in QI theory and design. Rising second-year residents received a day-long workshop on the basics of QI principles. Residents worked in teams to develop and implement QI projects. Self-assessed QI proficiency was measured prior to and immediately following the workshop. QI knowledge was assessed with the Quality Improvement Knowledge Application Tool (QIKAT) at baseline and following project completion. RESULTS: Two groups of residents (n=37) received training and completed at least 1 year on their projects. Analyses revealed that residents' self-assessed QI proficiency improved after receiving a day-long training workshop and was consistent for both groups of resident training. Application of QI knowledge as assessed by the QIKAT did not improve following QI project participation in resident Group 1 but did improve in resident Group 2. CONCLUSIONS: A formal QI curriculum was successfully developed and implemented into three family medicine residency programs. Residents' QI knowledge and skills improved following training and experience conducting QI projects. Faculty and resident commitment to the program and competing time demands proved challenging to the introduction of QI training. Future studies should assess residents' sustained learning and translating QI residency experiences into practice.

A rural community-based interdisciplinary curriculum: a social work perspective.

Although social workers are frequently part of interdisciplinary teams in health care and community settings, interdisciplinary training is often lacking in social work education (Berg-Weger & Schneider, 1998). This article describes a study of the effects of an interdisciplinary community-based experiential course preparing new health care professionals for work as part of interdisciplinary teams. The interdisciplinary curriculum was established for a summer course taught in 2006 by faculty from five disciplines: social work, nutrition, medicine, nursing, and public health. The course, Quality Improvement in Rural Healthcare, which focused on health literacy in people with a diagnosis of diabetes that live in northeast Tennessee, provided a model environment for learning interdisciplinary teamwork. Evaluation of this course found that social work students displayed a statistically significant increase in positive attitude toward interdisciplinary teamwork. Course strengths, weaknesses, obstacles, and opportunities for curriculum improvement are elaborated.