Outcomes After a Statewide Policy to Improve Evidence-Based Treatment of Back Pain Among Medicaid Enrollees in Oregon.

BACKGROUND: A novel Oregon Medicaid policy guiding back pain management combined opioid restrictions with emphasis on non-opioid and non-pharmacologic therapies. OBJECTIVE: To examine the effect of the policy on prescribing, health outcomes, and health service utilization. DESIGN: Using Medicaid enrollment, medical and prescription claims, prescription drug monitoring program, and vital statistics files, we analyzed the policy's association with selected outcomes using interrupted time series models. SUBJECTS: Adult Medicaid patients with back pain enrolled between 2014 and 2018. INTERVENTION: The Oregon Medicaid back pain policy. MAIN MEASURES: Opioid and non-opioid medication prescribing, procedural care, substance use and mental health conditions, and outpatient and inpatient healthcare utilization. KEY RESULTS: The policy was associated with decreases in the percentage of Medicaid enrollees with back pain receiving any opioids (- 2.68 percentage points [95% CI - 3.14, - 2.23] level, - 1.01 pp [95% CI - 1.1, - 0.92] slope), days of short-acting opioid use (- 0.4 days [95% CI - 0.53, - 0.26] slope), receipt of more than 7 days of short-acting opioids (- 2.36 pp [95% CI - 2.76, - 1.95] level, - 0.91 pp [95% CI - 1, - 0.83] slope), chronic opioid use (- 1.27 pp [95% CI - 1.59, - 0.94] level, - 0.46 [95% CI - 0.53, - 0.39 slope), and spinal surgeries and procedures. Among secondary outcomes, we found no increase in opioid overdose and a small, statistically significant trend decrease in opioid use disorders. There were small increases in non-opioid substance use and mental health diagnoses and visits but no increase in self-harm. CONCLUSIONS: A state Medicaid policy emphasizing evidence-based back pain management was associated with decreases in opioid prescribing, spinal surgeries, and opioid use disorder trends, but also short-term increases in mental health encounters and an increase in non-opioid substance use disorder trends. Such policies may help reinforce evidence-based care, but must be designed with consideration of potential harms.

Pandemic phase-related racial and ethnic disparities in COVID-19 positivity and outcomes among patients presenting to emergency departments during the first two pandemic waves in the USA.

BACKGROUND: In many countries including the USA, the UK and Canada, the impact of COVID-19 on people of colour has been disproportionately high but examination of disparities in patients presenting to ED has been limited. We assessed racial and ethnic differences in COVID-19 positivity and outcomes in patients presenting to EDs in the USA, and the effect of the phase of the pandemic on these outcomes. METHODS: This is a retrospective cohort study of adult patients tested for COVID-19 during, or 14 days prior to, the index ED visit in 2020. Data were obtained from the National Registry of Suspected COVID-19 in Emergency Care network which has data from 155 EDs across 27 US states. Hierarchical models were used to account for clustering by hospital. The outcomes included COVID-19 diagnosis, hospitalisation at index visit, subsequent hospitalisation within 30 days and 30-day mortality. We further stratified the analysis by time period (early phase: March-June 2020; late phase: July-September 2020). RESULTS: Of the 26 111 adult patients, 38% were non-Hispanic White (NHW), 29% Black, 20% Hispanic/Latino, 3% Asian and 10% all others; half were female. The median age was 56 years (IQR 40-69), and 53% were diagnosed with COVID-19; of those, 59% were hospitalised at index visit. Of those discharged from ED, 47% had a subsequent hospitalisation in 30 days. Hispanic/Latino patients had twice (adjusted OR (aOR) 2.3; 95% CI 1.8 to 3.0) the odds of COVID-19 diagnosis than NHW patients, after adjusting for age, sex and comorbidities. Black, Asian and other minority groups also had higher odds of being diagnosed (compared with NHW patients). On stratification, this association was observed in both phases for Hispanic/Latino patients. Hispanic/Latino patients had lower odds of hospitalisation at index visit, but when stratified, this effect was only observed in early phase. Subsequent hospitalisation was more likely in Asian patients (aOR 3.1; 95% CI 1.1 to 8.7) in comparison with NHW patients. Subsequent ED visit was more likely in Blacks and Hispanic/Latino patients in late phase. CONCLUSION: We found significant differences in ED outcomes that are not explained by comorbidity burden. The gap decreased but persisted during the later phase in 2020.

Increased Use of Complementary and Alternative Therapies for Back Pain Following Statewide Medicaid Coverage Changes in Oregon.

BACKGROUND: In 2016, Oregon introduced a policy to improve back pain treatment among Medicaid enrollees by expanding benefits for evidence-based complementary and alternative medical (CAM) services and establishing opioid prescribing restrictions. OBJECTIVE: To examine changes in CAM utilization following the policy and variations in utilization across patient populations. DESIGN: A retrospective study of Oregon Medicaid claims data, examining CAM therapy utilization by back pain patients pre- vs post-policy. We used an interrupted time series analysis to evaluate changes in CAM use and examined the association between patient characteristics and CAM use post-policy using linear regression models. PARTICIPANTS: Adult Medicaid patients with back pain. INTERVENTION: The Oregon Medicaid back pain policy, administered through Coordinated Care Organizations (CCOs). MAIN MEASURES: Use of CAM services. KEY RESULTS: Use of any CAM service increased from 7.9% (95% CI 7.6-8.2%) prior to the policy to 30.9% (95% CI 30.4-31.3%) after the policy. Acupuncture increased from 0.3 to 5.6%, chiropractic from 0.3 to 11.1%, massage from 1.6 to 14.8%, PT/OT from 6.0 to 17.7%, and osteopathic from 1.4 to 1.9%. Interrupted time series showed an overall increase in proportion of back pain patients who used CAM service following the policy. Among those who accessed CAM, the policy did not appear to increase the number of services used. In the post period, CAM services were accessed more often by female and older enrollees and urban populations. Black, American Indian/Alaska Native, and Hispanic enrollees were less likely to access CAM services; for Black enrollees, this was true for all types of services. CONCLUSIONS: CAM service utilization increased among back pain patients following implementation of Oregon's policy. There was significant heterogeneity in uptake across service types, CCOs, and patient subgroups. Policymakers should consider implementation factors that might limit impact and perpetuate health disparities.

National Awards and Female Emergency Physicians in the United States: Is the "Recognition Gap" Closing?

BACKGROUND: Gender inequities in recognition, compensation, promotion, and leadership roles exist in emergency medicine. Formal recognition in the workplace and opportunities for advancement are vulnerable to bias. OBJECTIVE: To examine the gender distribution of national awards in emergency medicine, to analyze whether there is a gap, and to highlight notable trends. METHODS: Recipients of the major award categories between 2001 and 2020 were examined for the 3 main national emergency medicine organizations. The gender distribution of award winners by year was compared with the gender distribution of female faculty in emergency medicine departments using data from the Association of American Medical Colleges and a chi-squared analysis. RESULTS: The gender gap in award winners has decreased over time, but men are still disproportionately given national awards over women. In all 3 organizations, women represented a smaller proportion of award winners than men when compared with the national proportion of women in academic emergency medicine. Advocacy awards were the one category where women were more likely to be recognized. Women were notably least likely to receive clinical and leadership awards. CONCLUSIONS: The gender gap in emergency medicine awards has narrowed in the last 20 years but still exists. This discrepancy is an example of how bias can compound over time to generate gaps in recognition, career advancement, and promotion. The pipeline to award nominations should be addressed at the individual, departmental, awards committee, and organizational levels. © 2021 Elsevier Inc.

Emergency Department Patients are Receptive to Prayer-Based Interventions to Reduce Alcohol Use.

Previous studies show that elements of spirituality, including prayer and religious services, may contribute to reductions in harmful alcohol use. The objective of this study was to assess the acceptability of prayer as a component of emergency department (ED) interventions for risky alcohol use. A 12-question multiple-choice questionnaire was developed, piloted, and refined by the study team. The questionnaire included questions about current beliefs and attitudes toward prayer and assessed interest in various means of delivering prayer or prayer support for reducing alcohol use. The questionnaire was administered to a consecutive sample of 111 patients recruited from the 12-month follow-up of a parent RCT study on reducing alcohol use among injured ED patients (ReDIAL). To qualify for the parent study, participants needed an ASSIST v3.0 alcohol score ≥ 11. 90 participants (81%) consented to answer questions about prayer. The participating sample was 38% female and 29% nonwhite; mean age was 36 years. Of these participants, 64% reported that they currently pray; of those, 88% reported praying daily or weekly; 79% agreed that prayer helps with coping in difficult times; 68% agreed that prayer could assist in achieving difficult goals; and 48% agreed that prayer helps reduce alcohol use. Interest in various means of utilizing prayer to reduce alcohol use was assessed in all participants (regardless of whether they currently prayed or not): 45% were interested in having others pray for them to reduce alcohol use; 40% were interested in receiving text reminders to pray; 42% were interested in receiving text messages with specific prayers to use; and 47% were interested in receiving text messages that someone was praying for them. 33.3% of the entire sample stated that they would attend services if provided information on spiritual or religious groups in the community. The incorporation of prayer in alcohol interventions was considered acceptable by a proportion of our sample of risky alcohol users, even those who do not currently use prayer as a resource in their lives. Given the promising data on ED patients' perceptions of the significance and acceptability of spiritual practices in reducing alcohol use, prayer may emerge as a useful adjunctive tool in future ED interventions for alcohol use disorders.

"Sometimes You Feel Like the Freak Show": A Qualitative Assessment of Emergency Care Experiences Among Transgender and Gender-Nonconforming Patients.

STUDY OBJECTIVE: Transgender, gender-variant, and intersex (trans) people have decreased access to care and poorer health outcomes compared with the general population. Little has been studied and documented about such patients' emergency department (ED) experiences and barriers to care. Using survey and qualitative research methods, this study aims to identify specific areas for improvement and generate testable hypotheses about the barriers and challenges for trans individuals needing acute care. METHODS: A survey and 4 focus groups were conducted with trans individuals older than 18 years who had been to an ED in the last 5 years. Participants were recruited by trans e-mail listservs; outreach to local trans organizations; and lesbian, gay, bisexual, and transgender periodical advertisements. The interview guide was reviewed by qualitative research and trans health content experts. Deidentified participant demographic information was collected with a standardized instrument. All discussions were captured on digital audio recorders and professionally transcribed. Interview coding and thematic analysis were conducted with a grounded theory approach. RESULTS: Among 32 participants, 71.9% were male identified and 78.1% were white. Nearly half (43.8%) reported avoiding the ED when they needed acute care. The factors that had the greatest influence on ED avoidance were fear of discrimination, length of wait, and negative previous experiences. There were 4 overarching discussion themes: system structure, care competency, discrimination and trauma, and avoidance of emergency care. Improvement recommendations focused on staff and provider training about gender and trans health, assurance of private gender identity disclosure, and accurate capture of sex, gender, and sexual orientation information in the electronic medical record. CONCLUSION: Efforts to improve trans ED experiences should focus on provider competency and communication training, electronic medical record modifications, and assurance of private means for gender disclosure. Future research directions include quantifying the frequency of care avoidance, the effect of avoidance on trans patient morbidity and mortality, and comparing ED patient outcomes by gender identity. Further research with increased inclusion of transwomen and people of color is needed to identify themes that may not have been raised in this preliminary investigation.

The Prescription Opioid Epidemic: Social Media Responses to the Residents' Perspective Article.

In June 2014, Annals of Emergency Medicine collaborated with the Academic Life in Emergency Medicine (ALiEM) blog-based Web site to host an online discussion session featuring the Annals Residents' Perspective article "The Opioid Prescription Epidemic and the Role of Emergency Medicine" by Poon and Greenwood-Ericksen. This dialogue included a live videocast with the authors and other experts, a detailed discussion on the ALiEM Web site's comment section, and real-time conversations on Twitter. Engagement was tracked through various Web analytic tools, and themes were identified by content curation. The dialogue resulted in 1,262 unique page views from 433 cities in 41 countries on the ALiEM Web site, 408,498 Twitter impressions, and 168 views of the video interview with the authors. Four major themes about prescription opioids identified included the following: physician knowledge, inconsistent medical education, balance between overprescribing and effective pain management, and approaches to solutions. Free social media technologies provide a unique opportunity to engage with a diverse community of emergency medicine and non-emergency medicine clinicians, nurses, learners, and even patients. Such technologies may allow more rapid hypothesis generation for future research and more accelerated knowledge translation.

BSAFER: A Web-based intervention for drug use and intimate partner violence demonstrates feasibility and acceptability among women in the emergency department.

BACKGROUND: Addressing violence along with drug use change goals is critical for women with coexisting intimate partner violence (IPV) and substance use disorders (SUDs). METHODS: This was an acceptability and feasibility study of BSAFER, a brief Web-based program and booster phone call addressing violence and drug use. A screening survey identified women with recent drug use and IPV in the emergency department (ED). Participants were randomized to BSAFER or a Web-based control program and booster call providing education about home fire safety. Program completion, usability, satisfaction, and motivational interviewing (MI) adherence were primary outcomes. Drug use and IPV outcomes were measured at baseline, 1 month, and 3 months. RESULTS: Forty women were enrolled (21 BSAFER, 19 control); 50% were nonwhite and mean age was 30 years. The most commonly used drugs were marijuana (88%) and cocaine (30%); 45% reported physical abuse, and 33% reported severe combined physical and sexual abuse. Thirty-nine (98%) completed the Web program, 30 (75%) completed the booster, and 29 (73%) completed the 3-month follow-up. Mean System Usability Scale (SUS) for the BSAFER Web program was 84 (95% confidence interval [CI]: 78-89) of 100; mean Client Satisfaction Questionnaire (CSQ-8) was 28 (95% CI: 26-29) of 32. MI adherence scores were high and similar for both the Web program and the booster. Both intervention and control groups had small mean decreases in weekly drug use days (0.7 vs. 1.5 days); participants using drugs other than marijuana demonstrated greater average reductions in drug use than those using marijuana only. CONCLUSIONS: An ED Web-based intervention for SUDs and IPV in women demonstrated feasibility and acceptability. Future studies will examine efficacy of the BSAFER program and investigate whether specific subgroups of drug using women may be most responsive to ED-based Web interventions.

"Why Is This Patient Being Sent Here?": Communication from Urgent Care to the Emergency Department.

BACKGROUND: Despite patients' increasing use of urgent care centers (UCC), little is known about how urgent care clinicians communicate with the emergency department (ED). OBJECTIVES: To assess ED clinicians' perceptions of the quality and consistency of communication when patients are referred from UCCs to EDs. METHODS: Emergency medicine department chairs distributed a brief, electronic survey to a statewide sample of ED clinicians via e-mail. The survey included multiple-choice and free-text questions focused on types of communication desired and received from UCCs, types of test results available on transfer, and suggestions for improvement. RESULTS: Of 199 ED clinicians, 102 (51.3%) responded. More than four out of five respondents "somewhat" or "strongly agreed" that each of the following would be helpful: a telephone call, the reason for referral, specific concern, a copy of the chart, and UCC contact information. However, ED clinicians reported not consistently receiving these: only a fifth (21.6%) of clinicians reported receiving the specific concern for their last 5 patients transferred from a UCC, and 34.3% recalled receiving a copy of the chart. Overall, 54.9% reported receiving laboratory test results "often or almost always," 49.0% electrocardiograms, and 44.1% imaging reports. Qualitative analysis revealed several themes: incomplete data when patients are referred; barriers to discussion between ED and urgent care clinicians; and possible solutions to improve communication. CONCLUSIONS: Our findings highlight variation in communication from UCCs to EDs, indicating a need to improve communication standards and practices. We identify several potential ways to improve this clinical information hand-off.

Twitter as a tool for communication and knowledge exchange in academic medicine: A guide for skeptics and novices.

Twitter is a tool for physicians to increase engagement of learners and the public, share scientific information, crowdsource new ideas, conduct, discuss and challenge emerging research, pursue professional development and continuing medical education, expand networks around specialized topics and provide moral support to colleagues. However, new users or skeptics may well be wary of its potential pitfalls. The aims of this commentary are to discuss the potential advantages of the Twitter platform for dialogue among physicians, to explore the barriers to accurate and high-quality healthcare discourse and, finally, to recommend potential safeguards physicians may employ against these threats in order to participate productively.

Risk of motor vehicle collision associated with cannabis and alcohol use among patients presenting for emergency care.

BACKGROUND: The objective of this study was to examine the relationship between cannabis and alcohol use and occurrence of motor vehicle collision (MVC) among patients in the emergency department (ED). METHODS: This was a cross-sectional study of visits to EDs in Denver, CO, Portland, OR, and Sacramento, CA by drivers who were involved in MVCs and presented with injuries (cases) and non-injured drivers (controls) who presented for medical care. We obtained blood samples and measured delta-9-THC and its metabolites. Alcohol levels were determined by breathalyzer or samples taken in the course of clinical care. Participants completed a research-assistant-administered interview consisting of questions about drug and alcohol use prior to their visit, context of use, and past-year drug and alcohol use. Multiple logistic regression was used to estimate the association between MVC and cannabis/alcohol use, adjusted for demographic characteristics. We then stratified participants based on levels of cannabis use and calculated the odds of MVC across these levels, first using self-report and then using blood levels for delta-9-THC in separate models. We conducted a case-crossover analysis, using 7-day look-back data to allow each participant to serve as their own control. Sensitivity analyses examined the influence of usual use patterns and driving in a closed (car, truck, van) versus open (motorcycle, motorbike, all-terrain vehicle) vehicle. RESULTS: Cannabis alone was not associated with higher odds of MVC, while acute alcohol use alone, and combined use of alcohol and cannabis were both independently associated with higher odds of MVC. Stratifying by level of self-reported or measured cannabis use, higher levels were not associated with higher odds for MVC, with or without co-use of alcohol; in fact, high self-reported acute cannabis use was associated with lower odds of MVC (odds ratio [OR] 0.18, 95% confidence interval [CI] 0.05-0.65). In the case-crossover analysis, alcohol use alone or in combination with cannabis was associated with higher odds of MVC, while cannabis use alone was again associated with decreased odds of MVC. CONCLUSIONS: Alcohol use alone or in conjunction with cannabis was consistently associated with higer odds for MVC. However, the relationship between measured levels of cannabis and MVC was not as clear. Emphasis on actual driving behaviors and clinical signs of intoxication to determine driving under the influence has the strongest rationale.