Opioid use disorder in pregnancy: leveraging provider perceptions to inform comprehensive treatment.

BACKGROUND: Medications for opioid use disorder (MOUD) are recommended with adjuvant behavioral therapies, counseling, and other services for comprehensive treatment of maternal opioid use disorder. Inadequate access to treatment, lack of prescribing providers and complex delivery models are among known barriers to care. Multi-disciplinary provider input can be leveraged to comprehend factors that facilitate or inhibit treatment. The objective of this study is to explore provider perceptions of MOUD and factors critical to comprehensive treatment delivery to improve the care of pregnant women with opioid use disorder. METHODS: A qualitative research approach was used to gather data from individual provider and group semi-structured interviews. Providers (n = 12) responded to questions in several domains related to perceptions of MOUD, treatment delivery, access to resources, and challenges/barriers. Data were collected, transcribed, coded (by consensus) and emerging themes were analyzed using grounded theory methodology. RESULTS: Emerging themes revealed persistent gaps in treatment and challenges in provider, health systems and patient factors. Providers perceived MOUD to be a "lifeline" to women. CONCLUSIONS: Inconsistencies in treatment provision, access and uptake can be improved by leveraging provider perceptions, direct experiences and recommendations for an integrated team-based, patient-centered approach to guide the care of pregnant women with opioid use disorder.

Practice Transformation Analytics Dashboard for Clinician Engagement.

PURPOSE: Practice transformation in primary care is a movement toward data-driven redesign of care, patient-centered care delivery, and practitioner activation. A critical requirement for achieving practice transformation is availability of tools to engage practices. METHODS: A total of 48 practices with 109 practice sites participate in the Garden Practice Transformation Network in Maryland (GPTN-Maryland) to work together toward practice transformation and readiness for the Quality Payment Program implemented by the Centers for Medicare & Medicaid Services. Practice-specific data are collected in GPTN-Maryland by practices themselves and by practice transformation coaches, and are provided by the Centers for Medicare & Medicaid Services. These data are overwhelming to practices when presented piecemeal or together, a barrier to practices taking action to ensure progress on the transformation spectrum. The GPTN-Maryland team therefore created a practice transformation analytics dashboard as a tool to present data that are actionable in care redesign. RESULTS: When practices reviewed their data provided by the Centers for Medicare & Medicaid Services using the dashboard, they were often seeing, for the first time, cost data on their patients, trends in their key performance indicator data, and their practice transformation phase. Overall, 72% of practices found the dashboard engaging, and 48% found the data as presented to be actionable. CONCLUSIONS: The practice transformation analytics dashboard encourages practices to advance in practice transformation and improvement of patient care delivery. This tool engaged practices in discussions about data, care redesign, and costs of care, and about how to develop sustainable change within their practices. Research is needed to study the impact of the dashboard on costs and quality of care delivery.

Buprenorphine Prescribing and Challenges Faced Among National Health Service Corps Clinicians.

Importance: The National Health Service Corps (NHSC) Loan Repayment Program (LRP) expansion in fiscal year (FY) 2019 intended to improve access to medication for opioid use disorder (MOUD) by adding more clinicians who could prescribe buprenorphine. However, some clinicians still face barriers to prescribing, which may vary between rural and nonrural areas. Objective: To examine the growth in buprenorphine prescribing by NHSC clinicians for Medicaid beneficiaries during the NHSC LRP expansion and describe the challenges to prescribing that persist in rural and nonrural areas. Design, Setting, and Participants: This cross-sectional study analyzed preexpansion and postexpansion Medicaid claims data to evaluate the percentage of prescriptions of buprenorphine filled during FY 2017 through 2021. This study also analyzed challenges and barriers to prescribing MOUD between rural and urban areas, using results from annual surveys conducted with NHSC clinicians and sites from FY 2019 through FY 2021. Exposure: Prescribing of buprenorphine by NHSC clinicians. Main Outcomes and Measures: The main outcomes were the percentage and number of Medicaid beneficiaries with opioid use disorder (OUD) who filled a prescription for buprenorphine before and after the LRP expansion and the challenges NHSC clinicians and sites faced in providing substance use disorder and OUD services. Survey results were analyzed using descriptive statistics. Results: During FYs 2017 through 2021, 7828 NHSC clinicians prescribed buprenorphine (standard LRP: mean [SD] age, 38.1 [8.4] years and 4807 females [78.9%]; expansion LRPs: mean [SD] age, 39.4 [8.1] years and 1307 females [75.0%]). A total of 3297 NHSC clinicians and 4732 NHSC sites responded to at least 1 survey question to the 3 surveys. The overall percentage of Medicaid beneficiaries with OUD who filled a prescription for buprenorphine during the first 2.5 years post expansion increased significantly from 18.9% before to 43.7% after expansion (an increase of 123 422 beneficiaries; P < .001). The percentage more than doubled among beneficiaries living in areas with a high Social Vulnerability Index score (from 17.0% to 36.7%; an increase of 31 964) and among beneficiaries living in rural areas (from 20.8% to 55.7%; an increase of 45 523). However, 773 of 2140 clinicians (36.1%; 95% CI, 33.6%-38.6%) reported a lack of mental health services to complement medication for OUD treatment, and 290 of 1032 clinicians (28.1%; 95% CI, 24.7%-31.7%) reported that they did not prescribe buprenorphine due to a lack of supervision, mentorship, or peer consultation. Conclusions and Relevance: These findings suggest that although the X-waiver requirement has been removed and Substance Abuse and Mental Health Services Administration guidelines encourage all eligible clinicians to screen and offer patients with OUD buprenorphine, as permissible by state law, more trained health care workers and improved care coordination for counseling and referral services are needed to support comprehensive OUD treatment.

Role of the National Health Service Corps in Delivering Substance Use Disorder Treatment in Underserved Communities.

OBJECTIVE: To help address the opioid epidemic, the U.S. Health Resources and Services Administration expanded the National Health Service Corps (NHSC) to include two new loan repayment programs (LRPs)-the Substance Use Disorder LRP and the Rural Community LRP-to supplement the existing standard LRP. In this article, the authors aimed to describe the role of these NHSC programs in addressing workforce shortages and providing substance use disorder treatment, including for opioid use disorder, in underserved areas. METHODS: Administrative data on NHSC clinician locations were merged with county-level data to characterize the communities served by NHSC clinicians. Primary data from surveys and key informant interviews with NHSC site administrators (N=9) and clinicians (N=9) were used to describe changes in NHSC clinician service delivery due to the COVID-19 pandemic. RESULTS: The NHSC LRP expansion increased the number of clinicians providing behavioral health treatment in underserved areas, especially rural areas. A majority of NHSC sites surveyed have increased their provision of substance use disorder treatment since the COVID-19 pandemic began. CONCLUSIONS: This article demonstrates the valuable role of these NHSC programs as resources that policy makers can use to mitigate the challenges of health care workforce shortages and burnout.

Framework for fiscal impact analysis of managing initial caries lesions with noninvasive therapies.

BACKGROUND: Evidence-based noninvasive caries therapies for initial caries lesions are available in the United States. Fundamental differences between noninvasive therapies and the traditional surgical dental approach warrant a study of the financial scalability. METHODS: The financial costs and benefits of fee-for-service clinics and payors were compared across 11 scenarios simulating the treatment of 1,000 initial caries lesions during a 3-year period. The scenarios included varying combinations of noninvasive therapies (that is, silver diamine fluoride, self-assembling peptide P11-4, and glass ionomer therapeutic sealants), no treatment, and various rates of 1- through 3-surface restorations to an estimated 2022 practice model. We used a decision tree microsimulation model for deterministic and probabilistic sensitivity analyses. We derived assumptions from an initial lesion and noninvasive therapy-focused cohort study with operations data from 16 sites accepting Medicaid in Alabama as a case study and clinical data from all 92 sites. RESULTS: In comparison with the 2022 practice model assumed for this study, scenarios that produce mutually beneficial results for payors' savings and clinics' net profits and profit margins include self-assembling peptide P11-4, silver diamine fluoride on nonesthetic surfaces, and a mix of 3 noninvasive therapies. When considering the limited resources of chair and clinician time, the same scenarios, as well as silver diamine fluoride with restorations, emerged with substantially higher clinic net profit. CONCLUSIONS: Hypothetical scenarios that include noninvasive therapies and minimize restorations achieve improved outcomes for all parties. PRACTICAL IMPLICATIONS: Payors and clinicians should explore and implement noninvasive caries therapies to improve oral health for all. This study was registered at ClinicalTrials.gov. The registration number is NCT04933331.

Prioritizing Flexibility, Human Connection, and Representation: Findings from the Qualitative Process Evaluation of the Special Projects of National Significance Black Men Who Have Sex with Men Initiative.

Previous research has identified significant unmet need for behavioral health care services for Black men who have sex with men (Black MSM); this challenge has been linked to poorer overall health and well-being. Health Resources and Services Administration (HRSA) funded a Special Projects of National Significance (SPNS) Initiative, Implementation of Evidence-Informed Behavioral Health Models to Improve HIV Health Outcomes for Black Men who have Sex with Men, with a goal to integrate behavioral health and clinical care services using four different evidence-informed models of care, ultimately improving HIV health outcomes. NORC at the University of Chicago conducted a multisite evaluation to assess the success of this Initiative, including a qualitative process evaluation that examined adaptations, services, integration activities, recruitment methods, and fidelity. The process evaluation described methods and processes used by demonstration sites to achieve their goals. This included challenges or barriers to implementation and the associated adaptations, notably due to the COVID-19 Public Health Emergency. Our study found key themes that indicated successful implementation were flexible service delivery, human connection, and client representation. We recommend future replicators apply these lessons learned in diverse health care and community settings that serve Black MSM. Additional information about the interventions can be found on TargetHIV.

Evaluating Evidence-Informed Behavioral Health Models to Improve HIV Health Outcomes: Quantitative Findings from the Ryan White HIV/AIDS Program Special Projects of National Significance Black Men Who Have Sex with Men Initiative.

The Black Men who have Sex with Men (MSM) Initiative was implemented at eight sites to engage and retain Black MSM in HIV medical care and supportive services (SS) by addressing their behavioral health (BH) care needs. Using a pre-post design and generalized logistic mixed-effects models adjusting for patient-level random effects, site, baseline age, and baseline mental health status, we evaluated whether participants experienced increased postintervention attainment of (1) Awareness of HIV medical care, BH care, and SS; (2) Screening, referral, linkage, receipt, and engagement in HIV care, BH care, and SS; and (3) Retention, antiretroviral therapy prescription, and suppressed viral load. Among 758 evaluated participants, the proportion of participants who were aware of, screened for, screened positive for, and referred to BH and SS, retention in care (72% to 79%), and viral load suppression (68% to 75%) increased between baseline and postintervention. Among participants who screened positive and received BH services were statistically more likely to be linked to [OR, 1.34 (95% CI: 1.08-1.66)] and retained in [OR, 1.36 (95% CI: 1.00-1.83)] care. Among those who screened positive and received SS were statistically more likely to be retained in care [OR, 1.54 (95% CI: 1.07-2.22)]. Measures of linkage to care declined significantly during the study period, perhaps because of COVID-19 that delayed in-person care. This study suggests that interventions designed to increase utilization of BH services and SS can be effective at improving retention in care and viral load suppression among Black MSM, at least among those currently using HIV services.

Assessment of Changes in Visits and Antibiotic Prescribing During the Agency for Healthcare Research and Quality Safety Program for Improving Antibiotic Use and the COVID-19 Pandemic.

Importance: The Agency for Healthcare Research and Quality (AHRQ) Safety Program for Improving Antibiotic Use aimed to improve antibiotic prescribing in ambulatory care practices by engaging clinicians and staff to incorporate antibiotic stewardship into practice culture, communication, and decision-making. Little is known about implementation of antibiotic stewardship in ambulatory care practices. Objective: To examine changes in visits and antibiotic prescribing during the AHRQ Safety Program. Design, Setting, and Participants: This cohort study evaluated a quality improvement intervention in ambulatory care throughout the US in 389 ambulatory care practices from December 1, 2019, to November 30, 2020. Exposures: The AHRQ Safety Program used webinars, audio presentations, educational tools, and office hours to engage stewardship leaders and clinical staff to address attitudes and cultures that challenge judicious antibiotic prescribing and incorporate best practices for the management of common infections. Main Outcomes and Measures: The primary outcome of the Safety Program was antibiotic prescriptions per 100 acute respiratory infection (ARI) visits. Data on total visits and ARI visits were also collected. The number of visits and prescribing rates from baseline (September 1, 2019) to completion of the program (November 30, 2020) were compared. Results: Of 467 practices enrolled, 389 (83%) completed the Safety Program; of these, 292 (75%) submitted complete data with 6 590 485 visits to 5483 clinicians. Participants included 82 (28%) primary care practices, 103 (35%) urgent care practices, 34 (12%) federally supported practices, 39 (13%) pediatric urgent care practices, 21 (7%) pediatric-only practices, and 14 (5%) other practice types. Visits per practice per month decreased from a mean of 1624 (95% CI, 1317-1931) at baseline to a nadir of 906 (95% CI, 702-1111) early in the COVID-19 pandemic (April 2020), and were 1797 (95% CI, 1510-2084) at the end of the program. Total antibiotic prescribing decreased from 18.2% of visits at baseline to 9.5% at completion of the program (-8.7%; 95% CI, -9.9% to -7.6%). Acute respiratory infection visits per practice per month decreased from baseline (n = 321) to a nadir of 76 early in the pandemic (May 2020) and gradually increased through completion of the program (n = 239). Antibiotic prescribing for ARIs decreased from 39.2% at baseline to 24.7% at completion of the program (-14.5%; 95% CI, -16.8% to -12.2%). Conclusions and Relevance: In this study of US ambulatory practices that participated in the AHRQ Safety Program, significant reductions in the rates of overall and ARI-related antibiotic prescribing were noted, despite normalization of clinic visits by completion of the program. The forthcoming AHRQ Safety Program content may have utility in ambulatory practices across the US.

Implementation of an Antibiotic Stewardship Program in Long-term Care Facilities Across the US.

IMPORTANCE: Antibiotic overuse in long-term care (LTC) is common, prompting calls for antibiotic stewardship programs (ASPs) designed for specific use in these settings. The optimal approach to establish robust, sustainable ASPs in LTC facilities is unknown. OBJECTIVES: To determine if the Agency for Healthcare Research and Quality (AHRQ) Safety Program for Improving Antibiotic Use, an educational initiative to establish ASPs focusing on patient safety, is associated with reductions in antibiotic use in LTC settings. DESIGN, SETTING, AND PARTICIPANTS: This quality improvement study including 439 LTC facilities in the US assessed antibiotic therapy data following a pragmatic quality-improvement program, which was implemented to assist facilities in establishing ASPs and with antibiotic decision-making. Training was conducted between December 2018 and November 2019. Data were analyzed from January 2019 to December 2019. INTERVENTIONS: Fifteen webinars occurred over 12 months (December 2018 to November 2019), accompanied by additional tools, activities, posters, and pocket cards. All clinical staff were encouraged to participate. MAIN OUTCOMES AND MEASURES: The primary outcome was antibiotic starts per 1000 resident-days. Secondary outcomes included days of antibiotic therapy (DOT) per 1000 resident-days, the number of urine cultures per 1000 resident-days, and Clostridioides difficile laboratory-identified events per 10 000 resident-days. All outcomes compared data from the baseline (January-February 2019) to the completion of the program (November-December 2019). Generalized linear mixed models with random intercepts at the site level assessed changes over time. RESULTS: Of a total 523 eligible LTC facilities, 439 (83.9%) completed the safety program. The mean difference for antibiotic starts from baseline to study completion per 1000 resident-days was -0.41 (95% CI, -0.76 to -0.07; P = .02), with fluoroquinolones showing the greatest decrease at -0.21 starts per 1000 resident-days (95% CI, -0.35 to -0.08; P = .002). The mean difference for antibiotic DOT per 1000 resident-days was not significant (-3.05; 95% CI, -6.34 to 0.23; P = .07). Reductions in antibiotic starts and use were greater in facilities with greater program engagement (as measured by webinar attendance). While antibiotic starts and DOT in these facilities decreased by 1.12 per 1000 resident-days (95% CI, -1.75 to -0.49; P < .001) and 9.97 per 1000 resident-days (95% CI, -15.4 to -4.6; P < .001), respectively, no significant reductions occurred in low engagement facilities. Urine cultures per 1000 resident-days decreased by 0.38 (95% CI, -0.61 to -0.15; P = .001). There was no significant change in facility-onset C difficile laboratory-identified events. CONCLUSIONS AND RELEVANCE: Participation in the AHRQ safety program was associated with the development of ASPs that actively engaged clinical staff in the decision-making processes around antibiotic prescriptions in participating LTC facilities. The reduction in antibiotic DOT and starts, which was more pronounced in more engaged facilities, indicates that implementation of this multifaceted program may support successful ASPs in LTC settings.

A systematic review of dental-related emergency department among Medicaid beneficiaries.

OBJECTIVES: Dental-related emergency department (ED) visits are a growing public health concern. Dental insurance coverage is a strong predictor of dental service access. The objective of this study was to conduct a systematic review to assess the incidence of dental-related ED visits for Medicaid dental enrollees compared to those with other insurances. METHODS: PubMed, EMBASE, and Google Scholar were searched for surveillance and observational data published in English from January 1999 to April 2020 to address the following PECOT question: Do patients with nontraumatic dental conditions (NTDC) (P1), or patients with any dental condition (P2) who have Medicaid (E) compared to other insurance status (private insurance, Medicare, no insurance) (C) have a differential incidence of single dental-related ED visits (O) in the literature search results from 1999 to April 2020 (T)? A critical appraisal was performed using a combination of the AXIS tool (for cross-sectional studies with observational data and MetaQAT (for public health evidence). RESULTS: This systematic review included 32 studies. Overall, risk of bias was low. Due to significant statistical heterogeneity, a synthesis without meta-analysis was conducted. NTDC ED visits ranged from 16.0 percent to 79.8 percent for Medicaid patients and 0.9 percent to 57.2 percent for uninsured patients. The range for any dental visit to the ED was 2.2-63.8 percent for Medicaid patients and 2.9-40.8 percent for uninsured patients. CONCLUSIONS: The results of this study support expanding insurance coverage in Medicaid programs to reduce ED use for NTDC visits in the United States.

Association of Criminal Statutes for Opioid Use Disorder With Prevalence and Treatment Among Pregnant Women With Commercial Insurance in the United States.

Importance: Inadequate treatment of opioid use disorder (OUD) in pregnant women increases the risk of life-threatening consequences on maternal and fetal outcomes. Untreated OUD during pregnancy is associated with higher rates of adverse outcomes among newborns. Objective: To examine the variation in the prevalence of OUD and the use of medication-assisted treatment among commercially insured pregnant women according to region and state legislature. Design, Setting, and Participants: Cohort study in which the patient cohort used was derived from a 10% random sample of enrollees within the IQVIA PharMetrics Plus adjudicated claims and enrollment database from 2007 to 2015. The database consists of a 10% random sample of private health insurance recipients in the United States and contains claims and enrollment data that are representative of the commercially insured US population. The cohort comprised women (n = 110 285) between 18 and 45 years of age with a code indicating a delivery and continuous insurance enrollment 9 months before and 12 months after delivery. Data analysis was performed from December 2017 to May 2018. Exposures: Based on their state of residence, the women were classified into 4 different regions: South, Midwest, West, and Northeast. Those residing in states with statutes that imposed civil or criminal penalties for OUD diagnosis during pregnancy were placed in a separate population from those residing in states without these statutes. Main Outcomes and Measures: Diagnosis of OUD in the 9 months before delivery and the receipt of medication-assisted treatment in the 9 months before or 12 months after delivery. Results: The 110 285 pregnant women included in the analysis had a mean (SD) age of 30.26 (5.59) years, with most (67 771 [61.5%]) falling within the 26- to 35-year age range. Of this cohort, 277 women (0.25%) had a diagnosis of OUD and 312 (0.28%) received treatment. Among the 277 women with OUD, 127 (45.9%) received treatment. The prevalence of an OUD diagnosis and receipt of treatment within regions was statistically significant (OUD diagnosis by region: Midwest, 0.05%; North, 0.09%; South, 0.06%; West, 0.06%; χ23 = 45.1148 [P < .001]; OUD treatment by region: Midwest, 0.05%; North, 0.08%; South, 0.10%; West, 0.05%; χ23 = 26.5654 [P < .001]). The prevalence of OUD diagnosis was also statistically significant when comparing women residing in states with statutes with those in states without statutes (OUD diagnosis by criminal statutes: criminalization, 0.07%; no criminalization, 0.18%; χ21 = 14.6456 [P < .001]; OUD treatment by criminal statutes: criminalization, 0.12%; no criminalization, 0.17%; χ21 = 0.0895); the receipt of treatment was not statistically significant (P = .76). Conclusions and Relevance: These results appeared to show significant variations in the patterns of OUD diagnosis and receipt of medication-assisted treatment among pregnant women, suggesting the need to further explore the source of these variations.