Stakeholder perspectives on a telemedicine referral and coordination model to expand medication treatment for opioid use disorder in rural primary care clinics.

INTRODUCTION: Opioid overdose deaths are increasing rapidly in the United States. Medications for opioid use disorder (MOUD) are effective and can be delivered in primary care, but uptake has been limited in rural communities. Referral to and coordination with an external telemedicine (TM) vendor by rural primary care clinics for MOUD (TM-MOUD) may increase MOUD access for rural patients, but we know little about perspectives on this model among key stakeholders. As part of a TM-MOUD feasibility study, we explored TM-MOUD acceptability and feasibility among personnel and patients from seven rural primary care clinics and a TM-MOUD vendor. METHODS: We conducted virtual interviews or focus groups with clinic administrators (n = 7 interviews), clinic primary care and behavioral health providers (8 groups, n = 30), other clinic staff (9 groups, n = 37), patients receiving MOUD (n = 16 interviews), TM-MOUD vendor staff (n = 4 interviews), and vendor-affiliated behavioral health and prescribing providers (n = 17 interviews). We asked about experiences with and acceptability of MOUD (primarily buprenorphine) and telemedicine (TM) and a TM-MOUD referral and coordination model. We conducted content analysis to identify themes and participants quantitatively rated acceptability of TM-MOUD elements on a 4-item scale. RESULTS: Perceived benefits of vendor-based TM-MOUD included reduced logistical barriers, more privacy and less stigma, and access to services not available locally (e.g., counseling, pain management). Barriers included lack of internet or poor connectivity in patients' homes, limited communication and trust between TM-MOUD and clinic providers, and questions about the value to the clinic of TM-MOUD referral to external vendor. Acceptability ratings for TM-MOUD were generally high; they were lowest among frontline staff. CONCLUSIONS: Rural primary care clinic personnel, TM-MOUD vendor personnel, and patients generally perceived referral from primary care to a TM-MOUD vendor to hold potential for increasing access to MOUD in rural communities. Increasing TM-MOUD uptake requires buy-in and understanding among staff of the TM-MOUD workflow, TM services offered, requirements for patients, advantages over clinic-based or TM services from clinic providers, and identification of appropriate patients. Poverty, along with patient hesitation to initiate treatment, creates substantial barriers to MOUD treatment generally; insufficient internet availability creates a substantial barrier to TM-MOUD.

Care coordination between rural primary care and telemedicine to expand medication treatment for opioid use disorder: Results from a single-arm, multisite feasibility study.

PURPOSE: The use of telemedicine (TM) has accelerated in recent years, yet research on the implementation and effectiveness of TM-delivered medication treatment for opioid use disorder (MOUD) has been limited. This study investigated the feasibility of implementing a care coordination model involving MOUD delivered via an external TM provider for the purpose of expanding access to MOUD for patients in rural settings. METHODS: The study tested a care coordination model in 6 rural primary care sites by establishing referral and coordination between the clinic and a TM company for MOUD. The intervention spanned approximately 6 months from July/August 2020 to January 2021, coinciding with the peak of the COVID-19 pandemic. Each clinic tracked patients with OUD in a registry during the intervention period. A pre-/post-intervention design (N = 6) was used to assess the clinic-level outcome as patient-days on MOUD based on patient electronic health records. FINDINGS: All clinics implemented critical components of the intervention, with an overall TM referral rate of 11.7% among patients in the registry. Five of the 6 sites showed an increase in patient-days on MOUD during the intervention period compared to the 6-month period before the intervention (mean increase per 1,000 patients: 132 days, P = .08, Cohen's d = 0.55). The largest increases occurred in clinics that lacked MOUD capacity or had a greater number of patients initiating MOUD during the intervention period. CONCLUSIONS: To expand access to MOUD in rural settings, the care coordination model is most effective when implemented in clinics that have negligible or limited MOUD capacity.

An introduction to avian and pandemic influenza.

There are many types of influenza viruses, which cause illness in a variety of birds and mammals. New strains are constantly evolving, causing seasonal influenza epidemics in humans. This article provides information about influenza and influenza viruses, and the three influenza pandemics of the twentieth century. Pandemic influenza is differentiated from avian influenza, which is a viral disease that primarily infects birds. The current outbreak of avian influenza H5N1 in poultry flocks across the world is unprecedented in its spread. Human infection with avian influenza is rare and for most strains the symptoms are usually mild. A notable exception is HN51, where almost 60 per cent of the currently recorded 251 human cases have died. While the risk of a pandemic occurring in the current circumstances is unknown, there is a high level of concern worldwide.

Equity in health care from a communitarian standpoint.

Equity in health and health care is an important issue. It has been proposed that the pursuit of equity in health care is being hampered by the dominance of individualism in health care practices. This paper explores the way in which communitarian ideals and practices might lend themselves to the pursuit of equity. Communitarians acknowledge, respect and foster the bonds that unite and identify communities. The paper argues that, to achieve equity in health care, these bonds need to be recognised and harnessed rather than ignored. The notion of individual autonomy in the context of the community is examined. Alternative concepts of autonomy--social autonomy and community autonomy--are seen to be more respectful and nurturing of both the individual and the community. Moreover, these concepts appear desirable for the pursuit of health care equity goals. The paper concludes with some thoughts about how equity in Australia's health care system can reasonably progress within a communitarian vision. Disadvantaged communities are discussed throughout, in particular, Australian Aboriginal communities.