A Quality Improvement Initiative Addressing Safe Opioid Prescribing and Disposal Postcesarean Delivery.

BACKGROUND: Misuse of prescription opioids is a public health crisis in the United States. In 2016, it was estimated that 3.3 million Americans were misusing prescription opioids (SAMHSA, 2017) and nearly 63,632 deaths were due to prescription opioid misuse. From 1999 to 2010, the number of prescription opioid drugs sold to health care facilities from pharmaceutical companies, nearly quadrupled. Cesarean delivery is the most common surgical procedure performed in the United States and opioids are most often chosen to manage post-operative pain. Research has shown that women, who deliver via cesarean section, are prescribed an excess of opioid tablets upon discharge and often store them in unsecure locations. Furthermore, the vast majority, are not disposed of properly. AIMS: The purpose of this quality improvement project was to assess whether a shared decision-making tool between a discharging obstetric provider and post-cesarean section patient can reduce the pool of unused opioids in the community. DESIGN: A one-group pre/post survey design was used to conduct this study. SETTING: 537-bed teaching hospital composed of 12 labor, delivery and recovery suites, 3 operating suites, and 33 postpartum suites. PARTICIPANTS: Engish speaking women, 18 years or older who delivered by cesarean section. METHODS: A shared decision-making session was implemented on a computer-based tablet, led by the discharge provider and woman following cesarean section on day of discharge. The tool focused on pain expectations, multi-modal methods (both pharmacologic and non-pharmacologic) to manage pain, safe storage, and disposal of excess medication. Women chose the number of 5-mg oxycodone tablets they would be prescribed, up to the institutional standard of 30. Women were provided a home opioid deactivation system to dispose of any excess tablets. A follow-up phone call was completed two weeks following discharge. RESULTS: Sixty women participated in the initiative. The mean number of 5-mg oxycodone tablets prescribed was 18. Women consumed a mean of 13 tablets, with 6 remaining. Eighty-eight percent (n = 33) of women disposed of their excess tablets, with 52% utilizing the opioid deactivation system provided. The initiative resulted in 92% (n = 47) of patients utilizing all of their prescribed tablets or properly disposing of them. CONCLUSION: Engaging post-operative patients in decisions regarding pain management, educating women on multi-modal methods to manage pain, and providing women with a means to properly dispose of excess tablets, can reduce opioid tablets available for misuse and diversion in the community.

Interprofessional collaboration and smartphone use as promising strategies to improve prenatal oral health care utilization among US underserved women: results from a qualitative study.

BACKGROUND: Data on barriers and facilitators to prenatal oral health care among low-income US women are lacking. The objective of this study was to understand barriers/facilitators and patient-centered mitigation strategies related to the use of prenatal oral health care among underserved US women. METHODS: We used community-based participatory research to conduct two focus groups with eight pregnant/parenting women; ten individual in-depth interviews with medical providers, dental providers and community/social workers; and one community engagement studio with five representative community stakeholders in 2018-2019. Using an interpretive description research design, we conducted semi-structured interviews and focus groups which were audio-recorded, transcribed, and analyzed for thematic content. RESULTS: We identified individual and systemic barriers/facilitators to the utilization of prenatal oral health care by underserved US women. Strategies reported to improve utilization included healthcare system-wide changes to promote inter-professional collaborations, innovative educational programs to improve dissemination and implementation of prenatal oral health care guidelines, and specialized dental facilities providing prenatal oral health care to underserved women. Moreover, smartphones have the potential to be an innovative entry point to promote utilization of prenatal oral care at the individual level. CONCLUSIONS: Low-income women face multiple, addressable barriers to obtaining oral health care during pregnancy. Inter-professional collaboration holds strong promise for improving prenatal oral health care utilization.

Gastroenteritis in Children.

Acute gastroenteritis is defined as a diarrheal disease of rapid onset, with or without nausea, vomiting, fever, or abdominal pain. In the United States, acute gastroenteritis accounts for 1.5 million office visits, 200,000 hospitalizations, and 300 deaths in children each year. Evaluation of a child with acute gastroenteritis should include a recent history of fluid intake and output. Significant dehydration is unlikely if parents report no decrease in oral intake or urine output and no vomiting. The physical examination is the best way to evaluate hydration status. The four-item Clinical Dehydration Scale can be used to determine severity of dehydration based on physical examination findings. In children with mild illness, stool microbiological tests are not routinely needed when viral gastroenteritis is the likely diagnosis. Mild gastroenteritis in children can be managed at home. Oral rehydration therapy, such as providing half-strength apple juice followed by the child's preferred liquids, is the mainstay of treatment for mild dehydration and is as effective as intravenous rehydration for preventing hospitalization and return to the emergency department. Oral rehydration solutions are recommended for moderate dehydration. Ondansetron may be prescribed if needed to prevent vomiting and improve tolerance of oral rehydration solutions. Hospitalization and intravenous fluids are recommended for children who do not respond to oral rehydration therapy plus an antiemetic and patients with severe dehydration (i.e., signs of shock or more than 10% dehydration). Handwashing, breastfeeding, and rotavirus vaccination reduce the incidence of acute gastroenteritis in young children.

A Case of Internet Gaming Disorder: When #Play Apart Together Takes a Dark Turn.

Background: The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) places internet Gaming disorder (IGD) in its research appendix as a potential new behavioral addiction diagnosis that requires further investigation. As part of the media campaign #HealthyAtHome, recommendation to relieve stress and anxiety during COVID-19, the World Health Organization (WHO) advocated for the playing of video games. The encouragement and expansion of playing video games may have led to the unintentional consequence of increasing the prevalence of IGD as IGD has been postulated to be a maladaptive response to stress. Case: A 34 year old male presented to his primary care physician with decline in work function, increased depression, and anxiety. Before the COVID-19 pandemic he estimated that he spent 2 h a day playing games and socialized with friends weekly; however at the time of presentation, his social interactions were through online gaming only and he was playing games 14 h per day. The patient began paroxetine and bupropion, with good result, though declined concomitant psychotherapy. Discussion: Internet Gaming Disorder is a potential new behavioral addiction that is likely to increase in prevalence over the continuing course of the COVID-19 pandemic. While initial studies show promising effects of medication and psychosocial interventions, further study on standardized diagnostic criteria and effectiveness of treatment modalities is needed.

Attending a Biopsychosocially Focused Buprenorphine Training Improves Clinician Attitudes.

Objective: Substance use disorders remain highly stigmatized. Access to medications for opioid use disorder is poor. There are many barriers to expanding access including stigma and lack of medical education about substance use disorders. We enriched the existing, federally required, training for clinicians to prescribe buprenorphine with a biopsychosocial focus in order to decrease stigma and expand access to medications for opioid use disorder. Methods: We trained a family medicine team to deliver an enriched version of the existing buprenorphine waiver curriculum. The waiver training was integrated into the curriculum for all University of Rochester physician and nurse practitioner family medicine residents and also offered to University of Rochester residents and faculty in other disciplines and regionally. We used the Brief Substance Abuse Attitudes Survey to collect baseline and post-training data. Outcomes: 140 training participants completed attitude surveys. The overall attitude score increased significantly from pre to post-training. Additionally, significant changes were observed in non-moralism from pre-training (M = 20.07) to post-training (M = 20.98, p < 0.001); treatment optimism from pre-training (M = 21.56) to post-training (M = 22.33, p < 0.001); and treatment interventions from pre-training (M = 31.03) to post-training (M = 32.10, p < 0.001). Conclusion: Increasing medical education around Opioid Use Disorder using a Family Medicine trained team with a biopsychosocial focus can improve provider attitudes around substance use disorders. Enriching training with cases may improve treatment optimism and may help overcome the documented barriers to prescribing medications for opioid use disorder and increase access for patients to lifesaving treatments.

Increasing Access to Medications for Opioid Use Disorder in Primary Care: Removing the Training Requirement May Not Be Enough.

BACKGROUND: Substance use disorders, including opioid use disorder (OUD), are understood as chronic diseases with a relapsing and remitting course and no known cure. Medications for OUD (MOUD) are well established with decades of evidence supporting their safety and efficacy; however, treatment access remains poor and inequitable. Buprenorphine is an MOUD that can be prescribed in a primary care outpatient setting, although regulatory and administrative challenges are a barrier to prescribing it. Recent regulatory changes offer an opportunity to expand the number of family doctors who treat OUD. METHODS: We offered free, easily accessible buprenorphine "x-waiver training" led by a team of primary care clinicians. In addition, we provided wrap-around support for MOUD clinical questions and administrative needs with experienced family medicine mentors. RESULTS: More than 400 clinicians attended our trainings, including medical students, residents, and attending physicians. Of the 101 attending physicians who completed our trainings, only 30 went on to apply for an x-wavier, and of those only 7 were currently prescribing when contacted 12 months later. CONCLUSION: Our experience indicates that removing the training requirement is a necessary first step but is unlikely to result in major changes to rates of prescribing without other significant cultural changes.

Does Changing Residency Obstetric Call to a Group Model Significantly Impact Patient Continuity?

BACKGROUND AND OBJECTIVES: Group sharing of prenatal care and inpatient obstetric (OB) call is increasingly replacing single-provider longitudinal models including in family medicine (FM) residencies. Such change in care models could impact continuity of prenatal and delivery care.The University of Rochester's family medicine residency program changed the resident maternal care coverage to an obstetric group model from a single-provider model in 2016 to improve work-life balance, which provided an opportunity to examine how these two practice styles impacted provider continuity. METHODS: We performed a retrospective chart review of family medicine resident-assigned obstetric patients receiving care at the University of Rochester's residency clinic. The study evaluated provider continuity differences in two models of prenatal care and obstetric call: (1) single provider model (SPM) with one primary provider and one backup support resident vs (2) OB group-provider model (GPM) with three to four resident providers and one primary provider. RESULTS: The average number of different providers seen significantly increased in the GPM vs SPM (3.47 vs 2.87, P=.02), however the average percentage of prenatal visits with either a primary or designated backup provider was not statistically different (83.1% vs 90.1%, P=.07). Among delivery continuity measures, there was no significant difference between models in the percentage of deliveries attended by the primary or designated backup residents compared with nongroup providers. (76.9% vs 82.3%, P=.51). CONCLUSIONS: This study provides quantitative evidence on how differing models of residency maternal care coverage impact continuity of care. Study findings did not show an inferiority of an OB group-provider model compared to a single-provider model when considering how often patients were seen prenatally and delivered by providers from their continuity group.

Optimizing interconception care: Rationale for the IMPLICIT model.

Despite traditional prenatal interventions, the incidence of low birth weight and prematurity in the United States have not significantly decreased. Interconception care for women between pregnancies has been proposed as a method of improving various perinatal outcomes. Although broadly advocated by national groups, interconception care (ICC) has not been widely implemented. We describe best practices for an ICC model based on screening mothers for tobacco use, depression, folic acid intake, and inter-pregnancy interval at well child visits. Because of the model's flexibility, sites can readily customize implementation by incorporating the questions directly into existing workflows and using local service providers already working in maternal-child health. This model has demonstrated promising results and ease of implementation thus far, and offers great potential for improved perinatal outcomes and promotion of health equity.

45-year-old woman • fever and chills • diffuse abdominal pain • shortness of breath • Dx?

Fever and chills. Diffuse abdominal pain. Shortness of breath.

Clinician and Staff Perceptions of Barriers to Providing Contraception in Primary Care.

INTRODUCTION: Short interpregnancy periods increase the likelihood of preterm delivery and low birth weight,1 both of which are significant causes of infant morbidity and mortality.2 Since nearly half of pregnancies in the United States are unplanned,3 opportunities exist to better understand barriers to contraceptive services. Studying these barriers as perceived by clinical staff can better guide programs to improve interpregnancy spacing. METHODS: Between September and November 2017, 76 staff and 95 primary care clinicians from two family medicine residency practices (Highland Family Medicine (HFM) in Rochester, New York and St Margaret Family Medicine (SM) in Pittsburgh, Pennsylvania) completed surveys. Questions assessed perceived barriers to providing contraceptive services, contraception knowledge, and opportunities for improvement. Survey-based analysis focused on comparative descriptive statistics between staff and provider responses. RESULTS: Clinicians ranked side effects and patient lack of awareness and misconceptions about contraceptive methods more highly than staff (P=0.0073 and P=0.0001, respectively). Staff identified childcare and work absence as more significant barriers (P=0.0114 and P=0.0380, respectively). Providers felt appointment timing was the largest constraint to contraceptive care. Staff perceived financial limitations and scheduling to be the top barriers. Nonclinician staff exhibited significant knowledge gaps regarding contraception. CONCLUSIONS: Numerous modifiable barriers contribute to difficulty providing contraceptive services. Providers and staff largely agree on the perceived barriers, but there is a significant gap in nonclinician staff knowledge of contraception. Education can address one of the leading concerns, but improvement efforts should also address areas such as availability of devices, scheduling issues, and resident supervision.

A guide to providing wide-ranging care to newborns.

Here's how to refine your care, which includes an assessment of neonatal feedings, the evaluation of jaundice and fever, and the prevention of SIDS.

Age-related alterations in NOS and oxidative stress in mesenteric arteries from male and female rats.

Epidemiological evidence suggests that advancing age affects the cardiovascular system of men and women differently. The purpose of this study was to determine whether the effects of aging on nitric oxide synthase (NOS), oxidative stress, and vascular function are different in males and females. Mesenteric arteries from young (3 mo) and old (24 mo) male and female Fischer 344/Brown Norway rats were studied. Western blot analysis and NOS activity were performed on the homogenized mesenteric arterial bed separated into cytosolic and membrane-associated fractions. Plasma 8-isoprostane measurements assessed oxidative stress. Vascular reactivity was determined by using a wire myograph in the absence and presence of a NOS inhibitor, N(omega)-nitro-l-arginine, to examine endothelial function and basal and stimulated nitric oxide release. In additional arteries, reactivity was performed in the presence of polyethylene glycol-SOD to assess the impact of superoxide on vascular function. Among females, aging was associated with a decline in membrane-associated NOS activity and membrane-associated NOS III protein expression. Advancing age in males was associated with increased cytosolic NOS III protein expression. Among both males and females, advancing age resulted in increased oxidative stress. Vascular function was maintained with age in arteries from both males and females, and there was no difference in either basal or stimulated nitric oxide release with age. Despite sex-specific effects of advancing age on the NOS system and increases in markers of oxidative stress, vascular function is maintained in mesenteric arteries from aged Fischer 344/Brown Norway rats. These data suggest that age-related alterations in the resistance vasculature are complex and likely involve multiple compensating vasoactive pathways.

Avian use of perennial biomass feedstocks as post-breeding and migratory stopover habitat.

Increased production of biomass crops in North America will require new agricultural land, intensify the cultivation of land already under production and introduce new types of biomass crops. Assessing the potential biodiversity impacts of novel agricultural systems is fundamental to the maintenance of biodiversity in agricultural landscapes, yet the consequences of expanded biomass production remain unclear. We evaluate the ability of two candidate second generation biomass feedstocks (switchgrass, Panicum virgatum, and mixed-grass prairie) not currently managed as crops to act as post-breeding and fall migratory stopover habitat for birds. In total, we detected 41 bird species, including grassland specialists and species of state and national conservation concern (e.g. Henslow's Sparrow, Ammodramus henslowii). Avian species richness was generally comparable in switchgrass and prairie and increased with patch size in both patch types. Grassland specialists were less abundant and less likely to occur in patches within highly forested landscapes and were more common and likely to occur in larger patches, indicating that this group is also area-sensitive outside of the breeding season. Variation in the biomass and richness of arthropod food within patches was generally unrelated to richness and abundance metrics. Total bird abundance and that of grassland specialists was higher in patches with greater vegetation structural heterogeneity. Collectively, we find that perennial biomass feedstocks have potential to provide post-breeding and migratory stopover habitat for birds, but that the placement and management of crops will be critical factors in determining their suitability for species of conservation concern. Industrialization of cellulosic bioenergy production that results in reduced crop structural heterogeneity is likely to dramatically reduce the suitability of perennial biomass crops for birds.