RESUMEN
STUDY OBJECTIVE: We sought to determine the influence of the Levels of Care for Rhode Island Emergency Departments and Hospitals for Treating Overdose and Opioid Use Disorder (Levels of Care) on emergency department (ED) provision of take-home naloxone, behavioral counseling, and referral to treatment. METHODS: A retrospective analysis of Rhode Island ED visits for opioid overdose from 2017 to 2018 was performed using data from a statewide opioid overdose surveillance system. Changes in provision of take-home naloxone, behavioral counseling, and referral to treatment before and after Levels of Care implementation were assessed using interrupted time series analysis. We compared outcomes by hospital type using multivariable modified Poisson regression models with generalized estimating equation estimation to account for hospital-level variation. RESULTS: We analyzed 245 overdose visits prior to Levels of Care implementation (January to March 2017) and 1340 overdose visits after implementation (hospital certification to December 2018). After implementation, the proportion of patients offered naloxone increased on average by 13% (95% confidence interval [CI] 5.6% to 20.4%). Prior to implementation, the proportion of patients receiving behavioral counseling and treatment referral was declining. After implementation, this decline slowed and stabilized, and on average 18.6% more patients received behavioral counseling (95% CI 1.3% to 35.9%) and 23.1% more patients received referral to treatment (95% CI 2.7% to 43.5%). Multivariable analysis showed that after implementation, there was a significant increase in the likelihood of being offered naloxone at Level 1 (adjusted relative risk [aRR] 1.31 [95% CI 1.06 to 1.61]) and Level 3 (aRR 3.13 [95% CI 1.08 to 9.06]) hospitals and an increase in referrals for medication for opioid use disorder (from 2.5% to 17.8%) at Level 1 hospitals (RR 7.73 [95% CI 3.22 to 18.55]). Despite these increases, less than half of the patients treated for an opioid overdose received behavioral counseling or referral to treatment CONCLUSION: The establishment of ED policies for treatment and services after opioid overdose improved naloxone distribution, behavioral counseling, and referral to treatment at hospitals without previously established opioid overdose services. Future investigations are needed to better characterize implementation barriers and evaluate policy influence on patient outcomes.
Asunto(s)
Sobredosis de Droga/tratamiento farmacológico , Servicio de Urgencia en Hospital/estadística & datos numéricos , Naloxona/uso terapéutico , Antagonistas de Narcóticos/uso terapéutico , Trastornos Relacionados con Opioides/tratamiento farmacológico , Adulto , Consejo/estadística & datos numéricos , Femenino , Humanos , Análisis de Series de Tiempo Interrumpido , Masculino , Persona de Mediana Edad , Derivación y Consulta/estadística & datos numéricos , Estudios Retrospectivos , Rhode IslandAsunto(s)
Técnicas Bacteriológicas/métodos , Pruebas Diagnósticas de Rutina/métodos , Brotes de Enfermedades , Disentería Bacilar/diagnóstico , Disentería Bacilar/epidemiología , Reacción en Cadena de la Polimerasa Multiplex/métodos , Shigella/aislamiento & purificación , Adolescente , Adulto , Niño , Preescolar , Femenino , Humanos , Lactante , Masculino , Persona de Mediana Edad , Salud Pública , Rhode Island/epidemiología , Shigella/genética , Adulto JovenRESUMEN
CONTEXT: Although highly active antiretroviral therapy has improved survival among many HIV patients, there are still those with advanced illness and limited access to care who may benefit from palliative care and hospice. OBJECTIVES: To examine completion of advance directives, use of palliative care, and enrollment in hospice among HIV patients who receive care at an urban safety net hospital. METHODS: This was a retrospective cohort study of HIV patients in a large, urban safety net hospital in 2010. Physicians abstracted data from the electronic medical record on patient and clinical factors and end-of-life care use. Logistic regression examined predictors of hospice use. RESULTS: Overall, 367 HIV patients identified electronically by International Classification of Disease (ICD)-9 code were hospitalized in 2010. The mean age was 42 years, and 57% were African American. Although 28% died, only 6% of the sample received palliative care consultation, and 6% of the sample enrolled in hospice. Those who received hospice had lower albumin levels (adjusted odds ratio [AOR] 4.53, 95% CI 1.19-17.34) had received palliative care (AOR 9.73, 95% CI 2.10-45.09) and completed an advance directive (AOR 16.33, 95% CI 4.23-61.68). Of those patients who received hospice, the mean time to death after enrollment was 11 days. CONCLUSION: Among an urban cohort of HIV patients, the rates of advance directive completion, palliative care use, and hospice use were low. Despite advancements in the treatment of HIV, many patients with advanced illness may benefit from palliative care and hospice services. Advances should be made in identifying those patients earlier in their disease trajectories.
Asunto(s)
Infecciones por VIH/terapia , Cuidado Terminal/estadística & datos numéricos , Adulto , Planificación Anticipada de Atención/estadística & datos numéricos , Albúminas/metabolismo , Registros Electrónicos de Salud , Femenino , Infecciones por VIH/diagnóstico , Infecciones por VIH/epidemiología , Infecciones por VIH/metabolismo , Hospitales para Enfermos Terminales/estadística & datos numéricos , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Cuidados Paliativos/estadística & datos numéricos , Estudios Retrospectivos , Factores Socioeconómicos , Texas , Población UrbanaRESUMEN
Concern about the morbidity and mortality of hepatitis C infection is increasing. Persons born from 1945 to 1965 are most significantly affected, with the majority unaware of their infection, and will otherwise go untreated. Up to three-fourths of hepatitis C-related deaths occur in this population of "baby boomers." Since 2007, mortality from hepatitis C has exceeded that from HIV, nationally and in Rhode Island. New treatment options for hepatitis C emphasize the potential for cure of hepatitis C that is distinct from HIV. Financial resources and integration of hepatitis C partners and services in Rhode Island will be instrumental in reducing hepatitis C infections and increasing the number of cases cured. We describe public health investments in the past, present, and future to implement strategies for effectively addressing hepatitis C in the state.