Health and Economic Outcomes of Offering Buprenorphine in Homeless Shelters in Massachusetts.

Importance: Overdose is the leading cause of death among people experiencing homelessness (PEH), but engagement in medication treatment is low in this population. Shelter-based buprenorphine may be a strategy for increasing initiation and retention on lifesaving medications. Objective: To estimate clinical outcomes and conduct an economic analysis of statewide shelter-based opioid treatment in Massachusetts. Design, Setting, and Participants: This economic evaluation study in Massachusetts used a cohort state-transition simulation model. Two cohorts were modeled starting in 2013, including (1) a closed cohort of a fixed population of PEH with history of high-risk opioid use over their lifetimes and (2) an open cohort in which membership could change over time, allowing assessment of population-level trends over a 10-year period. Data analysis occurred from January 2023 to April 2024. Exposures: Model exposures included (1) no shelter-based buprenorphine (status quo) and (2) offering buprenorphine in shelters statewide. Main Outcomes and Measures: Outcomes included overdose deaths, quality-adjusted life-years (QALYs) gained, and health care and modified societal perspective costs. Sensitivity analyses were conducted on key parameters. Results: In the closed cohort analysis of 13 800 PEH (mean [SD] age, 40.4 [13.1] years; 8749 male [63.4%]), shelter-based buprenorphine was associated with an additional 65.4 person-weeks taking buprenorphine over an individual's lifetime compared with status quo. Shelter-based buprenorphine was cost saving when compared with the status quo, with a discounted lifetime cost savings from the health sector perspective of $1300 per person, and 0.2 additional discounted QALYs per person and 0.9 additional life-years per person. In the population-level simulation, 254 overdose deaths were averted over the 10-year period with the shelter-based buprenorphine strategy compared with the status quo (a 9.2% reduction of overdose deaths among PEH in Massachusetts). Overdose-related and other health care utilization undiscounted costs decreased by $3.0 million and $66.4 million, respectively. Shelter-based opioid treatment generated $44.7 million in additional medication and clinical costs, but saved $69.4 million in overdose and other health costs. Conclusions and Relevance: In this economic evaluation of clinical and economic outcomes among PEH, shelter-based buprenorphine was associated with fewer overdose deaths and was cost saving. These findings suggest that broad rollout of shelter-based buprenorphine may be an important tool in addressing the overdose crisis.

Characteristics of US hospitals using extraordinary collections actions against patients for unpaid medical bills: a cross-sectional study.

OBJECTIVE: This study aims to characterise and evaluate the largest 100 hospitals in the USA that have adopted aggressive collection tactics to pursue patients with unpaid medical bills, such as lawsuits, wage garnishments and liens. DESIGN: Cross-sectional study. SETTING: We examined state and county court record systems to measure the magnitude and prevalence of these practices at the largest 100 hospitals in the UA between 1 January 2018 and 31 July 2020. MAIN OUTCOMES MEASURES: The main outcome of this study was the number of lawsuits, wage garnishments and liens. A secondary outcome was the characterisation of a hospital's safety, charitability, size and financial practices. RESULTS: Between 1 January 2018 and 31 July 2020, 26 hospitals filed 38 965 court actions (lawsuits, wage garnishments and liens) against patients for unpaid medical debt. For 16 of 26 hospitals, the dollar amount pursued in the court claim was available for 100% of cases, totalling US$71.8 million. The average aggregate amount sought by hospital lawsuits during the study period was US$4.5 million. Three hospitals filed US$56.2 million in amounts pursued in court, or 78.3% of the total amount pursued by all hospitals in the sample. In the remaining 74 hospitals, the study team did not identify extraordinary collection actions through the court system. CONCLUSIONS: Standardised medical debt collections best practices and metrics of medical debt collections quality are needed to increase public accountability for hospitals, particularly non-profit hospitals. There is a need to re-evaluate Internal Revenue Service rules pertaining to non-profit hospitals' tax-exempt status to ensure tax-exempt hospitals provide community benefits commensurate with the value of tax exemption.

Internal Medicine Residency Program Directors' Screening Practices and Perceptions About Recruitment Challenges.

PURPOSE: To examine internal medicine residency program directors' (PDs') screening practices and perceptions about current recruitment challenges. METHOD: In March-May 2017, the Association of Program Directors in Internal Medicine Survey Committee sent a survey to 373 Alliance for Academic Internal Medicine member residency programs. PDs rated the importance of 23 inclusion and 11 exclusion criteria for interview invitation decision making, provided United States Medical Licensing Examination (USMLE) cutoff scores for U.S. medical school and international medical graduates, and indicated changes in recruitment practices due to application inflation, including their ability to conduct holistic review and interest in potential solutions to address application inflation. Exploratory factor analysis was used to identify and confirm factors that were most important to interview invitation decision making. RESULTS: The response rate for eligible programs was 64% (233/363). USMLE Step 2 Clinical Knowledge scores were the criteria most frequently reported to be "very important" (131/233, 57%). Among respondents who reported any criteria as "very important," 155/222 (70%) identified a single most important (SMI) criterion. Non-USMLE criteria were frequently reported as an SMI criterion (68%). Concerning exclusion criteria, 157/231 (68%) reported they "absolutely would not invite" applicants with hints of unprofessional behavior. Of the 214/232 (92%) who reported an increase in applications, 138 (64%) adjusted recruitment practices. Respondents were most interested in limiting the number of applications per applicant (163/231, 71%), allowing applicants to indicate high interest in a subset of programs (151/229, 66%), and creating a national database of qualities of matched applicants for each program (121/228, 53%). CONCLUSIONS: PDs rely heavily on USMLE scores when making interview invitation decisions. However, collectively, non-USMLE criteria were more frequently reported as an SMI criterion. Most programs adjusted recruitment practices to respond to application volume. Several potential solutions to address application inflation garnered wide support.

Improved Supervision and Safety of Discharges Through Formal Discharge Education.

The goal of this study is to evaluate change in residents' assessment of supervision and safety of the discharge process after formal discharge instruction education. An educational lecture and workshop addressing high-risk medications, medication reconciliation, follow-up, and handoffs were provided to internal medicine residents. Residents were given a longitudinal survey before and after the discharge education session. Significant improvement in perception was demonstrated in review of discharge instructions ( P < .001), review of new medications/side effects with patients ( P < .001), and review of discharge instructions with and receiving feedback from attending physicians ( P < .001). On review of 40 discharge instructions pre and post intervention, there was an improvement in completion of instructions for high-risk medications ( P < .05 [14 insulin, 26 anticoagulation]). This intervention was viewed positively by residents; more than two thirds of all residents favored a process of formal training over the current model of "training by doing."

Competency-Based Medical Education in the Internal Medicine Clerkship: A Report From the Alliance for Academic Internal Medicine Undergraduate Medical Education Task Force.

As medical educators continue to redefine learning and assessment across the continuum, implementation of competency-based medical education in the undergraduate setting has become a focus of many medical schools. While standards of competency have been defined for the graduating student, there is no uniform approach for defining competency expectations for students during their core clerkship year. The authors describe the process by which an Alliance for Academic Internal Medicine task force developed a paradigm for competency-based assessment of students during their inpatient internal medicine (IM) clerkship. Building on work at the resident and fellowship levels, the task force focused on the development of key learning outcomes as defined by entrustable professional activities (EPAs) that were specific to educational experiences on the IM clerkship, as well as identification of high-priority assessment domains. The work was informed by a national survey of clerkship directors.Six key EPAs emerged: generating a differential diagnosis, obtaining a complete and accurate history and physical exam, obtaining focused histories and clinically relevant physical exams, preparing an oral presentation, interpreting the results of basic diagnostic studies, and providing well-organized clinical documentation. A model for assessment was proposed, with descriptors aligned to the scale of supervision and mapped to Accreditation Council for Graduate Medical Education domains of competence. The proposed paradigm offers a standardized template that may be used across IM clerkships, and which would effectively bridge competency evaluation in the clerkship to fourth-year assessment as well as eventual postgraduate training.

Resident scores on a patient satisfaction survey: evidence for maintenance of communication skills throughout residency.

OBJECTIVE: To examine whether resident communication skills evaluated through patient satisfaction surveys demonstrate evidence of decline through the 3 years of internal medicine residency. METHODS: Data for this study were collected retrospectively from a database of patient satisfaction surveys completed for internal medicine residents at different levels of training. Patient satisfaction was measured with the Aggregated EVGFP (excellent, very good, good, fair, or poor) questionnaire recommended by the American Board of Internal Medicine. RESULTS: Over a span of 5 years (2005-2009), a total of 768 patient rating forms were completed for 67 residents during their 3 years of residency training. In postgraduate year (PGY)-1, the residents had a mean satisfaction rating of 4.33 ± 0.48 compared to a mean rating of 4.37 ± 0.45 in their PGY-3 year. Analysis of variance indicated no significant difference by PGY level. CONCLUSION: Our findings demonstrate that resident communication skills and patient satisfaction do not decline during the 3 years of residency. This is contrary to our hypothesis that patient satisfaction would worsen as residents progressed through training.