Inflammatory Bowel Disease Hospitalizations Are Similar for Patients Receiving Televisit-Delivered Outpatient Care and Those Receiving Traditional In-Person Care.

INTRODUCTION: The coronavirus disease 2019 pandemic resulted in widespread expansion of telehealth. However, there are concerns that telehealth-delivered outpatient care may limit opportunities for managing complications and preventing hospitalizations for patients with inflammatory bowel disease (IBD). We aimed to assess the association between outpatient IBD care delivered through televisit (video or phone) and IBD-related hospitalizations. METHODS: We conducted a case-control study of patients with IBD who had an IBD-related index hospitalization between April 2021 and July 2022 and received their care in the Veterans Health Administration. We matched these hospitalized patients to controls who were not hospitalized based on age, sex, race, Charlson comorbidity index, IBD type, IBD-related emergency department use, IBD-related hospitalizations, and outpatient gastroenterology visits in the preceding year. The variable of interest was the percentage of total clinic visits delivered through televisit in the year before the index hospitalization. We compared the risk of IBD-related hospitalization by exposure to televisit-delivered care using conditional logistic regression. RESULTS: We identified 534 patients with an IBD-related hospitalization and 534 matched controls without an IBD-related hospitalization during the study period. Patients with IBD with a higher percentage of televisit-delivered (vs in-person) outpatient care were less likely to be hospitalized during the study period (for every 10% increase in televisit use, odds ratio 0.97, 95% confidence interval 0.94-1.00; P = 0.03). DISCUSSION: Televisit-delivered outpatient IBD care is not associated with higher risk of IBD-related hospitalization. These findings may reassure clinicians that televisit-delivered outpatient care is appropriate for patients with complex chronic diseases such as IBD.

Association of licensure and relationship requirement waivers with out-of-state tele-mental health care, 2019-2021.

During the COVID-19 public health emergency, states waived in-state licensure and pre-existing patient-physician relationship requirements to increase access to care. We exploit this state telehealth policy variation to estimate the association of in-state licensure requirement waivers and pre-existing patient-physician relationship requirement waivers with out-of-state tele-mental health care utilization of patients diagnosed with COVID-19. Using claims from January 2019 until December 2021 of 2 037 977 commercially insured individuals in 3 metropolitan statistical areas (MSAs) straddling Midwestern state borders, we found increased out-of-state telehealth utilization as a share of out-of-state mental health care by 0.1411 and 0.0575 visits per month or 1679.76% and 467.48% after licensure and relationship waivers, respectively. Within-MSA analyses illustrate an urban-rural digital divide in out-of-state utilization as a share of total or telehealth mental health care. Our findings indicate waivers primarily enhance access to care of established patients by enabling the transition of in-person out-of-state health care online. Interstate medical licensure compact participation may provide broader access to out-of-state tele-mental health care than emergency waivers.

Comparison of Treatment Receipt and Hospitalization Among Patients With Stimulant Use Disorder and/or Opioid Use Disorder in the Veterans Health Administration.

OBJECTIVES: Stimulant use is a growing problem, but little is known about service utilization among patients with stimulant use disorder (StUD). In the context of the overdose crisis, much research has focused on patients with opioid use disorder (OUD). It is unclear how the characteristics, treatment receipt, and hospitalization of patients with StUD differ from patients with OUD. METHODS: Electronic health record data were extracted for national Veterans Health Administration patients with a visit from March 1, 2020, to February 28, 2021 with StUD and/or OUD (N = 132,273). We compared patients with StUD without OUD to those with (1) co-occurring StUD + OUD and (2) OUD without StUD. Patient characteristics, substance use disorder treatment, and hospitalizations in the year following patients' first study period visit were descriptively compared. Treatment and hospitalization were also compared in adjusted regression models. RESULTS: Compared with patients with OUD + StUD, those with StUD without OUD were less likely to receive outpatient (adjusted odds ratio [aOR] 0.49, 95% confidence interval [CI] 0.47-0.50) or any treatment (aOR 0.47, 95% CI 0.46-0.49). Compared with patients with OUD without StUD, those with StUD without OUD were less likely to receive outpatient (aOR 0.51, 95% CI 0.49-0.52) or any treatment (aOR 0.56, 95% CI 0.54-0.58) and more likely to receive residential treatment (aOR 2.18, 95% 2.05-2.30) and to be hospitalized (aOR 1.62, 95% 1.56-1.69). CONCLUSIONS: Patients with StUD may be less likely to receive treatment and more likely to be hospitalized than patients with OUD. Efforts focused on mitigating hospitalization and increasing treatment receipt for patients with StUD are needed.

Telehealth and delivery of alcohol use disorder treatment in the Veterans Health Administration.

BACKGROUND: The use of telehealth treatment of alcohol use disorder (AUD) has increased since the start of the COVID-19 pandemic. However, it is unclear which patients are using telehealth and how telehealth visits are associated with treatment duration. This study examined characteristics associated with telehealth use among Veterans Health Administration patients receiving AUD treatment. METHODS: Using a national retrospective cohort study, we examined data from March 01, 2020 to February 28, 2021 to: First, identify patient characteristics associated with (a) any telehealth versus only in-person care for AUD treatment, and (b) video (≥1 video visit) versus only telephone visits for AUD treatment (≥1 telephone visit, no video) among any telehealth users. This analysis used mixed-effects logistic regression models to adjust for potential correlation across patients treated at the same facility. Second, we assessed whether visit modality was associated with the amount of AUD treatment received (number of AUD psychotherapy visits or medication coverage days). This analysis used mixed-effects negative binomial regression models. RESULTS: Among 138,619 patients who received AUD treatment, 52.8% had ≥1 video visit, 38.1% had ≥1 telephone but no video visits, and 9.1% had only in-person visits. In the regression analyses, patients who were male or had an opioid or stimulant use disorder (compared to having no non-AUD substance use disorder) were less likely to receive any telehealth-delivered AUD treatment compared to only in-person AUD treatment. Among patients who received any telehealth-delivered AUD treatment, those who were ≥45 years old (compared to 18-29 years old), Black (compared to White), diagnosed with a cannabis or stimulant use disorder, or diagnosed with a serious mental illness were less likely to receive a video visit than only telephone visits. Receiving any AUD telehealth was associated with receiving more psychotherapy visits and medication coverage days than only in-person care. CONCLUSIONS: Telehealth, a common modality for AUD treatment, supported a greater number of psychotherapy visits and a longer duration of medication treatment for AUD. However, some groups were less likely to receive any video telehealth than telephone visits, suggesting that multiple treatment modalities should remain available to ensure treatment access.

Contingency management for substance use disorders in the U.S. Veterans Health Administration: 2018-2022.

INTRODUCTION: Contingency management (CM) is one of the most effective interventions for substance use disorders (SUDs), including stimulant use disorder. In the United States, the Veterans Health Administration (VHA) led the largest-scale rollout of CM in the US to date, but little is known about characteristics of patients treated and CM clinical practices. METHODS: In this retrospective cohort study, we used VHA electronic health records data to descriptively examine CM treatment course (e.g., number of visits, time between visits, duration of treatment episode) and characteristics of patients receiving CM for SUDs from 2018 to 2022. RESULTS: From January 2018 to September 2022, 2844 patients received CM at 90 VA Health Systems (including 98 VA Medical Center, 7 community-based outpatient clinics, and 15 other sites). The median number of CM visits was 8 (mean = 10.17, SD = 8.12) visits over the course of 1.5 months (median = 45 days, mean = 57.46 days, SD = 62.65). The target substance was stimulants in 86.42 % of visits. Average age of patients was 52.29 years (SD = 12.10), with 55.06 % of patients experiencing homelessness or housing instability, and 97.50 % of patients diagnosed with more than one SUD. Compared to the year prior to the COVID-19 pandemic (03/2019-02/2020; mean = 957.33, SD = 157.71 visits/month), CM visits declined by 83.20 % in the year following the pandemic (03/2020-02/2021; mean = 160.83, SD = 164.14), and have yet to return to pre-pandemic levels. CONCLUSIONS: The CM rollout has been markedly successful in the VHA, with adoption across multiple VHA sites within a complex patient population, indicating the potential for effective, more widespread CM implementation. At the same time, there was a considerable reduction in CM care during the COVID-19 pandemic and CM has not yet returned to pre-pandemic levels. Moreover, only a small minority of VA patients with stimulant use disorder have received CM. Given increasing rates of overdose, including stimulant-involved overdose, it is important to increase CM provision in VHA and non-VHA settings.

Testing a new model of telehealth-delivered treatment for primary care patients with alcohol use disorder: A randomized controlled trial protocol.

BACKGROUND: The majority of adults suffering from alcohol use disorders (AUD) do not receive treatment. To address this gap in care, we must develop new models to increase identification, engagement and delivery of accessible and effective treatment. This paper describes the protocol for a randomized controlled trial (RCT) testing a novel telehealth treatment model for primary care patients with untreated AUD. METHODS: We aim to recruit 300 adults across 2 healthcare systems for this two-arm RCT. Participants, initially identified for recruitment based on AUD-related indicators in their electronic health record (EHR), are RCT-eligible if they meet AUD criteria (mild, moderate, severe), report ≥ 3 drinking days/week in past 30 days, and have not received AUD psychotherapy in the past 90 days. Participants are randomized to an intervention or enhanced usual care control (EUC) condition, both individually-delivered. The intervention includes a telephone-delivered motivational interviewing (MI) engagement session and 8 sessions of MI-Cognitive Behavioral Therapy (MI-CBT). EUC involves AUD psychoeducation, advice to reduce drinking and seek treatment, and provision of community resources. Outcomes will be measured at 3-, 6-, and 12-months; primary outcomes include: AUD psychotherapy initiation and engagement (within the study and external community) and alcohol consumption (percent drinking days and heavy drinking days). CONCLUSIONS: This study addresses whether proactive patient identification and engagement and delivery of patient-centered telehealth psychotherapy to patients with untreated AUD is effective in increasing treatment use and improving alcohol outcomes. If effective, this could be a highly scalable model for reducing the public health impact of AUD. TRIAL REGISTRATION: ClinicalTrials.gov # NCT05410561. University of Michigan HUM00204315. Ann Arbor VA IRB #1655886.

Prescriptions for Buprenorphine in Michigan Following an Education Intervention.

Importance: Buprenorphine is an underused treatment for opioid use disorder (OUD) that can be prescribed in general medical settings. Founded in 2017, the Michigan Opioid Collaborative (MOC) is an outreach and educational program that aims to address clinician and community barriers to buprenorphine access; however, the association between the MOC and buprenorphine treatment is unknown. Objective: To evaluate the association between MOC service use and county-level temporal trends of density of buprenorphine prescribers and patients receiving buprenorphine. Design, Setting, and Participants: This cohort study exploited staggered implementation of MOC services across all Michigan counties. Difference-in-difference analyses were conducted by applying linear fixed-effects regression across all counties to estimate the overall association of MOC engagement with outcomes and linear regression for each MOC-engaged county separately to infer county-specific results using data from May 2015 to August 2020. Analyses were conducted from September 2021 to November 2023. Exposures: MOC engagement. Main Outcomes and Measures: County-level monthly numbers of buprenorphine prescribers and patients receiving buprenorphine (per 100 000 population). Results: Among 83 total counties, 57 counties (68.7%) in Michigan were engaged by MOC by 2020, with 3 (3.6%) initiating engagement in 2017, 19 (22.9%) in 2018, 27 (32.5%) in 2019, and 8 (9.6%) in 2020. Michigan is made up of 83 counties with a total population size of 9 990 000. A total of 5 070 000 (50.8%) were female, 1 410 000 (14.1%) were African American or Black, 530 000 (5.3%) were Hispanic or Latino, and 7 470 000 (74.7%) were non-Hispanic White. The mean (SD) value of median age across counties was 44.8 (6.4). The monthly increases in buprenorphine prescriber numbers in the preengagement (including all time points for nonengaged counties) and postengagement periods were 0.07 and 0.39 per 100 000 population, respectively, with the absolute difference being 0.33 (95% CI, 0.12-0.53) prescribers per 100 000 population (P = .002). The numbers of patients receiving buprenorphine increased by an average of 0.6 and 7.15 per 100 000 population per month in preengagement and postengagement periods, respectively, indicating an estimated additional 6.56 (95% CI, 2.09-11.02) patients receiving buprenorphine per 100 000 population (P = .004) monthly increase after engagement compared with before. Conclusions and Relevance: In this cohort study measuring buprenorphine prescriptions in Michigan over time, counties' engagement in OUD-focused outreach and clinician education services delivered by a multidisciplinary team was associated with a temporal increase in buprenorphine prescribers and patients receiving buprenorphine.

Treatment for Co-Occurring Stimulant and Opioid Use Disorders: Overcoming Barriers in the Era of Polysubstance Use.

This Viewpoint explores the current barriers to implementing contingency management treatment for individuals experiencing both opioid use and stimulant use disorders in the context of high numbers of US overdoses.