Finding social need-les in a haystack: ascertaining social needs of Medicare patients recorded in the notes of care managers.

BACKGROUND: Unmet social needs may impair health and access to health care, and intervening on these holds particular promise in high-risk patient populations, such as those with multiple chronic conditions. Our objective was to identify social needs in a patient population at significant risk-Medicare enrollees with multiple chronic illnesses enrolled in care management services-and measure their prevalence prior to any systematic screening. METHODS: We partnered with Renova Health, an independent Medicare Chronic Care Management (CCM) provider with patients in 10 states during our study period (January 2017 through August 2020). Our data included over 3,000 Medicare CCM patients, representing nearly 20,000 encounters. We used a dictionary-based natural language processing approach to ascertain the prevalence of six domains of barriers to care (food insecurity, housing instability, utility hardship) and unmet social needs (health care affordability, need for supportive services, transportation) in notes taken during telephonic Medicare CCM patient encounters. RESULTS: Barriers to care, specifically need for supportive services (2.4%) and health care affordability (0.8%), were the most prevalent domains identified. Transportation as a barrier to care came up relatively less frequently in CCM encounters (0.1%). Unmet social needs were identified at a comparatively lower rate, with potential housing instability (0.3%) flagged most followed by potential utility hardship (0.2%) and food insecurity (0.1%). CONCLUSIONS: There is substantial untapped opportunity to systematically screen for social determinants of health and unmet social needs in care management.

Integrated Model for Patient-Centered Advanced Liver Disease Care.

Advanced liver disease (AdvLD) is a high-risk common condition with a progressive, highly morbid, and often fatal course. Despite effective treatments, there are substantial shortfalls in access to and use of evidence-based supportive and palliative care for AdvLD. Although patient-centered, chronic illness models that integrate early supportive and palliative care with curative treatments hold promise, there are several knowledge gaps that hinder development of an integrated model for AdvLD. We review these evidence gaps. We also describe a conceptual framework for a patient-centered approach that explicates key elements needed to improve integrated care. An integrated model of AdvLD would allow clinicians, patients, and caregivers to work collaboratively to identify treatments and other healthcare that best align with patients' priorities.

Patient-Physician Discussions on Lung Cancer Screening: A Missed Teachable Moment to Promote Smoking Cessation.

INTRODUCTION: Little is known about whether patients and physicians perceive lung cancer screening (LCS) as a teachable moment to promote smoking cessation or the degree to which physicians in "real world" settings link LCS discussions with smoking cessation counseling. We sought to characterize patient and physician perspectives of discussions about smoking cessation during LCS. METHODS: We conducted a qualitative study (interviews and focus groups) with 21 physicians and 28 smokers screened in four diverse hospitals. Transcripts were analyzed for characteristics of communication about smoking cessation and LCS, the perceived effect on motivation to quit smoking, the degree to which physicians leverage LCS as a teachable moment to promote smoking cessation, and suggestions to improve patient-physician communication about smoking cessation in the context of LCS. RESULTS: Patients reported that LCS made them more cognizant of the health consequences of smoking, priming them for a teachable moment. While physicians and patients both acknowledged that smoking cessation counseling was frequent, they described little connection between their discussions regarding LCS and smoking cessation counseling. Physicians identified several barriers to integrating discussions on smoking cessation and LCS. They volunteered communication strategies by which LCS could be leveraged to promote smoking cessation. CONCLUSIONS: LCS highlights the harms of smoking to patients who are chronic, heavy smokers and thus may serve as a teachable moment for promoting smoking cessation. However, this opportunity is typically missed in clinical practice. IMPLICATIONS: LCS highlights the harms of smoking to heavily addicted smokers. Yet both physicians and patients reported little connection between LCS and tobacco treatment discussions due to multiple barriers. On-site tobacco treatment programs and post-screening messaging tailored to the LCS results are needed to maximize the health outcomes of LCS, including smoking quit rates and longer-term smoking-related morbidity and mortality.

"It's like a mirror image of my illness": Exploring Patient Perceptions About Illness Using Health Mind Mapping-a Qualitative Study.

BACKGROUND: A patient's self-management of chronic disease is influenced in part by their explanatory model of illness (EMI) and daily lived experiences (DLE). Unfortunately, assessing patient's EMI and using this information to engage patients in chronic illness self-management continues to be a challenge. OBJECTIVE: "Health mind mapping" (HMM) is a novel process that captures a patient's EMI and DLE through the use of a graphic representation of ideas. We aimed to explore patient's experiences using HMM. DESIGN: Qualitative study utilizing semi-structured interviews. PARTICIPANTS: Adult patients with uncontrolled type 2 diabetes from a primary care clinic. APPROACH: A facilitator guided 20 participants through the process of developing a health mind map. Subsequently, each participant completed a semi-structured interview about their experience with the process and perceptions about how their maps could be used. The process and interviews were video and audio recorded. We conducted a content analysis of the maps and a thematic analysis, using an inductive approach, of the interview data. RESULTS: Participants explored a wide range of EMs and DLEs in their HMM process. Participants reported that the HMM process (1) helped to develop insight about self and illness; (2) was a catalyst for wanting to take actions to improve illness; and (3) represented an opportunity to actively share illness experiences. They reported potential uses of the map: (1) to communicate about their illness to others in their social network; (2) to communicate about their illness to providers; (3) to help others with diabetes manage their illness; and (4) to encourage ongoing engagement in diabetes self-care. CONCLUSIONS: Participants reported that HMM helped them develop new insight about their illness and was a catalyst for encouraging them to take control of their illness. HMM has the potential to facilitate communication with providers and engage patients in collaborative goal setting to improve self-care in chronic illness.

Patient and Clinician Perspectives on Shared Decision-making in Early Adopting Lung Cancer Screening Programs: a Qualitative Study.

BACKGROUND: Guidelines recommend, and Medicare requires, shared decision-making between patients and clinicians before referring individuals at high risk of lung cancer for chest CT screening. However, little is known about the extent to which shared decision-making about lung cancer screening is achieved in real-world settings. OBJECTIVE: To characterize patient and clinician impressions of early experiences with communication and decision-making about lung cancer screening and perceived barriers to achieving shared decision-making. DESIGN: Qualitative study entailing semi-structured interviews and focus groups. PARTICIPANTS: We enrolled 36 clinicians who refer patients for lung cancer screening and 49 patients who had undergone lung cancer screening in the prior year. Participants were recruited from lung cancer screening programs at four hospitals (three Veterans Health Administration, one urban safety net). APPROACH: Using content analysis, we analyzed transcripts to characterize communication and decision-making about lung cancer screening. Our analysis focused on the recommended components of shared decision-making (information sharing, deliberation, and decision aid use) and barriers to achieving shared decision-making. KEY RESULTS: Clinicians varied in the information shared with patients, and did not consistently incorporate decision aids. Clinicians believed they explained the rationale and gave some (often purposely limited) information about the trade-offs of lung cancer screening. By contrast, some patients reported receiving little information about screening or its trade-offs and did not realize the CT was intended as a screening test for lung cancer. Clinicians and patients alike did not perceive that significant deliberation typically occurred. Clinicians perceived insufficient time, competing priorities, difficulty accessing decision aids, limited patient comprehension, and anticipated patient emotions as barriers to realizing shared decision-making. CONCLUSIONS: Due to multiple perceived barriers, patient-clinician conversations about lung cancer screening may fall short of guideline-recommended shared decision-making supported by a decision aid. Consequently, patients may be left uncertain about lung cancer screening's rationale, trade-offs, and process.

Qualitative analysis of patient-centered decision attributes associated with initiating hepatitis C treatment.

BACKGROUND: In this era of a constantly changing landscape of antiviral treatment options for chronic viral hepatitis C (CHC), shared clinical decision-making addresses the need to engage patients in complex treatment decisions. However, little is known about the decision attributes that CHC patients consider when making treatment decisions. We identify key patient-centered decision attributes, and explore relationships among these attributes, to help inform the development of a future CHC shared decision-making aid. METHODS: Semi-structured qualitative interviews with CHC patients at four Veterans Health Administration (VHA) hospitals, in three comparison groups: contemplating CHC treatment at the time of data collection (Group 1), recently declined CHC treatment (Group 2), or recently started CHC treatment (Group 3). Participant descriptions of decision attributes were analyzed for the entire sample as well as by patient group and by gender. RESULTS: Twenty-nine Veteran patients participated (21 males, eight females): 12 were contemplating treatment, nine had recently declined treatment, and eight had recently started treatment. Patients on average described eight (range 5-13) decision attributes. The attributes most frequently reported overall were: physical side effects (83%); treatment efficacy (79%), new treatment drugs in development (55%); psychological side effects (55%); and condition of the liver (52%), with some variation based on group and gender. Personal life circumstance attributes (such as availability of family support and the burden of financial responsibilities) influencing treatment decisions were also noted by all participants. Multiple decision attributes were interrelated in highly complex ways. CONCLUSIONS: Participants considered numerous attributes in their CHC treatment decisions. A better understanding of these attributes that influence patient decision-making is crucial in order to inform patient-centered clinical approaches to care (such as shared decision-making augmented with relevant decision-making aids) that respond to patients' needs, preferences, and circumstances.

'The thing is not knowing': patients' perspectives on surveillance of an indeterminate pulmonary nodule.

BACKGROUND: The hundreds of thousands of patients found to have a potentially malignant pulmonary nodule each year are faced with tremendous uncertainty regarding what the nodule is and how it should be evaluated. OBJECTIVE: To explore patients' responses to the detection and evaluation of a pulmonary nodule. DESIGN: Qualitative study based on four focus-group discussions. We performed inductive analysis using principles of grounded theory to identify themes relating to responses to the nodule and strategies to manage uncertainty. SETTING AND PARTICIPANTS: Twenty-two patients from two medical centres who were undergoing surveillance for an indeterminate pulmonary nodule. RESULTS: Patient responses to an indeterminate pulmonary nodule were varied and evolved over time. Although almost all patients reported an initial fear about cancer, subsequent depictions of the nodule diverged into four types defined on two dimensions: cognitive ('it's cancer' vs. 'I don't know what it is' vs. 'it's nothing serious') and emotional (anxiety vs. equanimity). Most eventually accepted that the nodule was unlikely to be malignant; however, some remained anxious, convinced the nodule could turn into cancer at any time and should be aggressively monitored for life. Patients used results of surveillance tests as well as their own strategies (e.g. vigilance for symptoms, information-seeking, contemplating and controlling modifiable risk factors, avoidance, faith) to manage uncertainty. CONCLUSIONS: Surveillance for a pulmonary nodule can weigh heavily on some patients for months or years. Our findings may help clinicians prepare patients with a newly detected pulmonary nodule for the burden of the prolonged uncertainty of surveillance.

Using patient-reported outcomes to assess and improve prostate cancer brachytherapy.

OBJECTIVE: To describe a successful quality improvement process that arose from unexpected differences in control groups' short-term patient-reported outcomes (PROs) within a comparative effectiveness study of a prostate brachytherapy technique intended to reduce urinary morbidity. PATIENTS AND METHODS: Patients planning prostate brachytherapy at one of three institutions were enrolled in a prospective cohort study. Patients were surveyed using a validated instrument to assess treatment-related toxicity before treatment and at pre-specified intervals. Unexpectedly, urinary PROs were worse in one of two standard brachytherapy technique control populations (US-BT1 and US-BT2 ). Therefore, we collaboratively reviewed treatment procedures, identified a discrepancy in technique, made a corrective modification, and evaluated the change. RESULTS: The patient groups were demographically and clinically similar. In the first preliminary analysis, US-BT2 patients reported significantly more short-term post-treatment urinary symptoms than US-BT1 patients. The study's treating physicians reviewed the US-BT1 and US-BT2 treatment protocols and found that they differed in whether they used an indwelling urinary catheter. After adopting the US-BT1 approach, short-term urinary morbidity in US-BT2 patients decreased significantly. Brachytherapy procedures were otherwise unchanged. CONCLUSION: Many procedures in cancer treatments are not evaluated, resulting in practice variation and suboptimal outcomes. Patients, the primary medical consumers, provide little direct input in evaluations of their care. We used PROs, a sensitive and valid measure of treatment-related toxicity, for quality assessment and quality improvement (QA/QI) of prostate brachytherapy. This serendipitous patient-centred QA/QI process may be a useful model for empirically evaluating complex cancer treatment procedures and for screening for substandard care.

Patterns of task and network actions performed by navigators to facilitate cancer care.

BACKGROUND: Patient navigation is a widely implemented intervention to facilitate access to care and reduce disparities in cancer care, but the activities of navigators are not well characterized. PURPOSE: The aim of this study is to describe what patient navigators actually do and explore patterns of activity that clarify the roles they perform in facilitating cancer care. METHODOLOGY/APPROACH: We conducted field observations of nine patient navigation programs operating in diverse health settings of the national patient navigation research program, including 34 patient navigators, each observed an average of four times. Trained observers used a structured observation protocol to code as they recorded navigator actions and write qualitative field notes capturing all activities in 15-minute intervals during observations ranging from 2 to 7 hours; yielding a total of 133 observations. Rates of coded activity were analyzed using numerical cluster analysis of identified patterns, informed by qualitative analysis of field notes. FINDINGS: Six distinct patterns of navigator activity were identified, which differed most relative to how much time navigators spent directly interacting with patients and how much time they spent dealing with medical records and documentation tasks. Navigator actions reveal a complex set of roles in which navigators both provide the direct help to patients denoted by their title and also carry out a variety of actions that function to keep the health system operating smoothly. PRACTICE IMPLICATIONS: Working to navigate patients through complex health services entails working to repair the persistent challenges of health services that can render them inhospitable to patients. The organizations that deploy navigators might learn from navigators' efforts and explore alternative approaches, structures, or systems of care in addressing both the barriers patients face and the complex solutions navigators create in helping patients.

Cost effectiveness of direct-acting antiviral therapy for treatment-naive patients with chronic HCV genotype 1 infection in the veterans health administration.

BACKGROUND & AIMS: The Veterans Health Administration (VHA) is the largest single provider of care for hepatitis C virus (HCV) infection in the United States. We analyzed the cost effectiveness of treatment with the HCV protease inhibitors boceprevir and telaprevir in a defined managed care population of 102,851 patients with untreated chronic genotype 1 infection. METHODS: We used a decision-analytic Markov model to examine 4 strategies: standard dual-therapy with pegylated interferon-alfa and ribavirin (PR), the combination of boceprevir and PR triple therapy, the combination of telaprevir and PR, or no antiviral treatment. A sensitivity analysis was performed. Sources of data included published rates of disease progression, the census bureau, and VHA pharmacy and hospitalization cost databases. RESULTS: The estimated costs for treating each patient were $8000 for PR, $31,300 for boceprevir and PR, and $41,700 for telaprevir and PR. Assuming VHA treatment rates of 22% and optimal rates of sustained virologic response, PR, boceprevir and PR, and telaprevir and PR would reduce relative liver-related deaths by 5.2%, 10.9%, and 11.5%, respectively. Increasing treatment rates to 50% would reduce liver-related deaths by 12%, 24.7%, and 26.1%, respectively. The incremental cost-effectiveness ratios were $29,184/quality-adjusted life-years for boceprevir and PR and $44,247/quality-adjusted life-years for telaprevir and PR vs only PR. With the current 22% treatment rate, total system-wide costs to adopt boceprevir and PR or telaprevir and PR would range from $708 to $943 million. CONCLUSIONS: Despite substantial up-front costs of treating HCV-infected patients in the VHA with PR, or telaprevir and PR, each regimen improves quality of life and extends life expectancy by reducing liver-related morbidity and mortality, and should be cost effective. Further efforts to expand access to direct-acting antiviral therapy are warranted.

Do better-rated navigators improve patient satisfaction with cancer-related care?

Patient navigation has emerged as a promising strategy for addressing racial-ethnic and socioeconomic disparities in cancer-related care. However, little is known about the impact of patients' perception of the quality of navigation on patient outcomes. We examined the impact of better-rated navigators on patients' satisfaction with cancer-related care. The sample included 1,593 adults (85.8% with abnormal cancer screening and 14.2% with confirmed cancer diagnosis) who received patient navigation. We defined better-rated navigators as those scoring above the first quartile of mean scores on the Patient Satisfaction with Interpersonal Relationship with Navigator scale. We defined patient satisfaction based on scores above or below the median of the Patient Satisfaction with Cancer-Related Care (PSCC) scale. We controlled for patient and site characteristics using backward selection logistic regression analyses. Among patients with abnormal screening, having a better-rated navigator was associated with higher score on the PSCC (p < 0.05). After controlling for other bivariate predictors of satisfaction (e.g., age, race, income, and household size), navigation by better-rated navigators was associated with a greater likelihood of having higher patient satisfaction [odds ratio (OR), 1.38; 95% confidence interval (CI), 1.05-1.82]. Similar findings between better-rated navigators and score on the PSCC were found for participants with diagnosed cancer (OR, 3.06; 95% CI, 1.56-6.0). Patients navigated by better-rated navigators reported higher satisfaction with their cancer-related care.

Patient Experience of Managing Adherence to Repeat Lung Cancer Screening.

Lung cancer screening (LCS) is a process involving multiple low-dose computed tomography (LDCT) scans over multiple years. While adherence to recommended follow-up is critical in reducing lung cancer mortality, little is known about factors influencing adherence following the initial LDCT scan. The purpose of this study was to examine patients' and providers' depictions of continued screening and their understandings of patients' decisions to return for follow-up. Qualitative methodology involves interviews with patients about their understanding of the screening process and perceptions of lung cancer risk, including motivations to adhere to follow-up screening and surveillance. Analysis of interview transcripts followed the general procedures of grounded theory methodology. Patient adherence to LCS was influenced by their understanding of the process of screening, and their expectations for the next steps. Perceptions of lung cancer risk and associated motivation were not static and changed throughout the screening process. Recognizing that patients' motivations may be dynamic over the course of screening and surveillance will assist providers in helping patients make decisions regarding continued engagement with LCS.

The chosen and the unchosen: How eligibility for liver transplant influences the lived experiences of patients with advanced liver disease.

Advanced liver disease is often uncurable and fatal. Liver transplant is the only curative option for patients with advanced, irreversible liver disease, but the need for new livers far exceeds the supply. Patients with the greatest need as well as the greatest likelihood of benefit, based on a complex array of biomedical and psychosocial considerations, are prioritized for transplant. The opportunity to receive a life-saving surgery no doubt has enormous consequences for patients and their healthcare providers, as does the absence of that opportunity. But these consequences are poorly characterized, especially for patients deemed poor candidates for liver transplant. Through in-depth interviews with patients living with advanced liver disease and the providers who care for them, we explore how eligibility status affects illness experiences, including patients' interactions with clinicians, knowledge about their disease, expectations for the future, and efforts to come to terms with a life-limiting illness. We describe how the clinical and social requirements needed to secure eligibility for liver transplant lend themselves to a clinical and cultural logic that delineates "worthy" and "unworthy" patients. We describe how providers and candidates discuss the possibility of moral redemption for such patients through transplant surgeries, a discourse notably absent among patients not eligible for transplant.

Motherhood, pregnancy and gateways to intervene in substance use disorder.

Motherhood increases women's use of health and social services, presenting opportunities to identify and refer women with substance use disorder (SUD) to treatment. We pooled 4 years (2015-2018) of cross-sectional data from National Survey on Drug Use and Health on women of child-bearing age (18-44) in the United States (n = 64,346). (1) We compared the use of services (health, social and criminal justice involvement) by SUD and 'motherhood' (pregnant or has one or more children under 18). We used multivariable logistic regression models to estimate the association between motherhood, SUD and their interaction with the use of services. (2) We estimated the association between the use of different services and SUD treatment use among women with SUD. Among women of child-bearing age, 9.7% had SUD. Mothers who had SUD were more likely to use social services (AOR = 1.48 [95% CI: 1.22, 1.79]) and mental health services compared with non-mothers who did not have SUD (AOR = 1.40 [95% CI: 1.19, 1.65]). The following factors were associated with increased odds of receiving SUD treatment among mothers: mental health treatment utilisation (AOR = 1.94 [95% CI: 1.29, 2.93]); Medicaid coverage (AOR = 2.48 [95% CI: 1.64, 3.76]); and criminal justice involvement (AOR = 3.38 [95% CI: 1.97, 5.80]). To increase treatment access, it is important to address women's different stages in life, including how to best engage women in SUD care across different settings.

Differential Gateways, Facilitators, and Barriers to Substance Use Disorder Treatment for Pregnant Women and Mothers: A Scoping Systematic Review.

OBJECTIVES: Access to substance use disorder (SUD) treatment is complex, and more so for pregnant women and mothers who experience unique barriers. This scoping systematic review aimed to summarize contemporary findings on gateways, facilitators, and barriers to treatment for pregnant women and mothers with SUD. METHODS: We used the scoping review methodology and a systematic search strategy via MEDLINE/PubMed and Google Scholar. The search was augmented by the similar article lists for sources identified in PubMed. Scholarly and peer-reviewed articles that were published in English from 1996 to 2019 were included. A thematic analysis of the selected studies was used to summarize pathways to SUD treatment and to identify research gaps. RESULTS: The analysis included 41 articles. Multiple gateway institutions were identified: health care settings, social service agencies, criminal justice settings, community organizations, and employers. Some of the identified facilitators and barriers to SUD treatment were unique to pregnant women and mothers (eg, fear of incarceration for child abuse). Both personal (emotional support and social support) and child-related factors (loss of children, suspension or termination of parental rights, the anticipation of reuniting with children) motivated women to seek treatment. Major access barriers included fear, stigma, charges of child abuse, inconvenience, and financial hardship. CONCLUSIONS: There has been progress in implementing different types of interventions and treatments for that were attentive to pregnant women and mothers' needs. We developed a conceptual model that characterized women's pathways to treatment by deciphering women's potential engagement in gateway settings.

Two mental models of integrated care for advanced liver disease: qualitative study of multidisciplinary health professionals.

OBJECTIVES: The purpose of this paper is to present two divergent mental models of integrated advanced liver disease (AdvLD) care among 26 providers who treat patients with AdvLD. SETTING: 3 geographically dispersed United States Veterans Health Administration health systems. PARTICIPANTS: 26 professionals (20 women and 6 men) participated, including 9 (34.6%) gastroenterology, hepatology, and transplant physicians, 2 (7.7%) physician assistants, 7 (27%) nurses and nurse practitioners, 3 (11.5%) social workers and psychologists, 4 (15.4%) palliative care providers and 1 (3.8%) pharmacist. MAIN OUTCOME MEASURES: We conducted qualitative in-depth interviews of providers caring for patients with AdvLD. We used framework analysis to identify two divergent mental models of integrated AdvLD care. These models vary in timing of initiating various constituents of care, philosophy of integration, and supports and resources needed to achieve each model. RESULTS: Clinicians described integrated care as an approach that incorporates elements of curative care, symptom and supportive care, advance care planning and end-of-life services from a multidisciplinary team. Analysis revealed two mental models that varied in how and when these constituents are delivered. One mental model involves sequential transitions between constituents of care, and the second mental model involves synchronous application of the various constituents. Participants described elements of teamwork and coordination supports necessary to achieve integrated AdvLD care. Many discussed the importance of having a multidisciplinary team integrating supportive care, symptom management and palliative care with liver disease care. CONCLUSIONS: Health professionals agree on the constituents of integrated AdvLD care but describe two competing mental models of how these constituents are integrated. Health systems can promote integrated care by assembling multidisciplinary teams, and providing teamwork and coordination supports, and training that facilitates patient-centred AdvLD care.

Prognosis conversations in advanced liver disease: A qualitative interview study with health professionals and patients.

Advanced Liver Disease (AdvLD) is common, morbid, and associated with high likelihood of death. Patients may not fully understand their prognosis and are often unprepared for the course of illness. Little is known about how and when to deliver prognosis-related information to patients with AdvLD, who should participate, and what should be discussed. We conducted in-depth interviews with a multi-profession sample of Hepatology clinicians and patients with AdvLD. Participants were drawn from three geographically diverse facilities (New England, Texas, California). We used inductive and deductive qualitative data analysis approaches to identify themes related to AdvLD prognosis discussions. Thematic analysis focused on content, timing, and participants' roles in prognosis discussions. In total, 31 patients with AdvLD and 26 multi-profession clinicians completed interviews. Most participants provided a broad conceptualization of prognosis beyond predictions of survival, including expectations about illness course, ways to manage or avoid complications and a need to address patients' emotions. Patients favored initiating discussions early in the AdvLD course and welcomed a multi-profession approach to conducting discussions. Clinicians favored a larger role for specialty physicians. All participants recognized that AdvLD prognosis discussions occur infrequently and favored a structured, standardized approach to broadly discussing prognosis. Patients with AdvLD and their clinicians favored a multifaceted approach to prognosis conversations including discussions of life expectancy, predictions about likely course of liver disease, and expected changes in function and capabilities over time. Structured and early prognosis discussions should be part of routine AdvLD care.

Estimating the impact on initiating medications for opioid use disorder of state policies expanding Medicaid and prohibiting substance use during pregnancy.

BACKGROUND: Medicaid expansion increased access to addiction treatment services for pregnant women. However, states' imposition of civil or criminal child abuse sanctions for drug use during pregnancy could inhibit access to treatment. We estimated the effects of Medicaid expansion on pregnant women's medications for opioid use disorder (MOUD) use, and its interaction with statutes that prohibit substance use during pregnancy. METHODS: Using the Treatment Episode Dataset for Discharge (2010-2018), we identified the initial treatment episode of pregnant women with opioid use disorder (OUD). We described changes in MOUD use and estimated adjusted difference-in-differences and event study models to evaluate differences in changes in MOUD between states that prohibit substance use during pregnancy and states that do not. FINDINGS: Among a total of 16,070 treatment episodes for pregnant women with OUD from 2010 to 2018, most (74%) were in states that expanded Medicaid. By one year post-expansion, the proportion of episodes receiving MOUD in states not prohibit substance use during pregnancy increased by 8.7% points (95% CI: 2.7, 14.7) from the pre-expansion period compared to a 5.6% point increase in states prohibiting substance use during pregnancy (95% CI: -3.3, 14.8). In adjusted event study analysis, the expansion was associated with an increase in MOUD use by 15.3% by year 2 in states not prohibiting versus 1.5% percentage points in states prohibiting substance use during pregnancy, respectively. CONCLUSIONS: State policies prohibiting substance use during pregnancy may limit the salutary effects of Medicaid expansion for pregnant women who could benefit from MOUD treatment.

Veterans Affairs and Rural Community Providers' Perspectives on Interorganizational Care Coordination: A Qualitative Analysis.

OBJECTIVE: To investigate challenges in care coordination between US Department of Veterans Affairs (VA) clinics and community providers serving rural veterans. METHODS: We completed qualitative interviews in 2017-2018 with a geographically diverse sample of 57 VA and community staff. Interviews were audio-recorded and transcribed verbatim. We used Rapid Qualitative Inquiry (RQI) to guide analyses. RESULTS: Results suggested 5 pivotal domains related to interorganizational care coordination at these sites: organizational mechanisms; organizational culture; relational coordination; contextual factors; and the role of the third party administrators charged with management of scheduling and reimbursement of community services through recent legislation. Across these domains, strategies to bridge gaps between organizations (eg, contracts with third party administrators, development of VA-based community care offices, provision of boundary-spanning staff) at times exacerbated coordination challenges. CONCLUSIONS: Steps taken to improve interorganizational care coordination between VA and community clinics may inadvertently complicate an already complex process. Our findings emphasize the importance of attending to key contextual barriers in coordinating care for rural veterans, and they illustrate the value of fundamental structural and relational approaches to enhancing such care coordination.

Provider and Practice Experience Integrating the Dose-HPV Intervention into Clinical Practice.

INTRODUCTION: Few studies have rigorously evaluated the drivers of successful implementation of interventions to improve human papillomavirus (HPV) vaccination rates. The aim of this study was to evaluate the implementation of Development of Systems and Education for HPV Vaccination (DOSE HPV), a performance improvement intervention. METHODS: Primary care providers (PCPs), nurses, and individuals with leadership roles from pediatric and family medicine practices who attended DOSE HPV intervention sessions participated in qualitative interviews immediately following intervention completion. The study team professionally transcribed interviews and performed qualitative coding using inductive methods. Final analysis employed the Promoting Action on Research implementation in Health Services (PARiHS) model. RESULTS: Twenty-six individuals participated: 12 PCPs, 5 nurses, and 9 individuals with dual leadership and PCP roles. Participants described five factors that they felt contributed to program success: (1) evidence-based, goal-directed education; (2) personalized data feedback; (3) clinical leadership support; (4) collaborative facilitation; (5) repeated contacts/longitudinal structure of the intervention. Barriers to implementing the intervention included: (1) inability to standardize workflow across practices; (2) low pediatric volume, (3) competing priorities/lack of incentives, (4) ineffective involvement of nurses, (5) poor communication between clinical leadership and staff. DISCUSSION: Although many HPV testing interventions have been implemented, findings have been mixed. It is clear that having an effective, evidence-based intervention by itself is not enough to get it into practice. Rather, it is crucial to consider implementation factors to ensure consistent implementation and sustainability. Key factors for the success of the DOSE HPV intervention appear to include a collaborative approach, provision of useful evidence to motivate behavior change, and repeated contacts to ensure accountability for implementing changes. Workflow issues, ineffective lines of communication, and competing priorities at both the visit and the patient and population management levels can hinder implementation.