Prior Periods of Abstinence Among Adults With an Alcohol Use Disorder: A Qualitative Template Analysis.

Abstaining from substance use is a goal of many people with alcohol use disorder (AUD). Understanding patient perspectives of a period of abstinence may assist persons with AUD in achieving this goal. We accessed the electronic health records of adults with AUD entering an emergency department in Baltimore, Maryland, who received a brief peer support intervention for substance use. Data contained open-ended text entered by staff after a patient indicated ever having a sustained period of substance abstinence. Using qualitative template analysis methodology, we identified codes and themes from these open-ended responses from N = 153 adults with AUD. The sample was primarily male (n = 109, 71.2%) and White (n = 98, 64.1%) with an average age of 43.8 years (SD = 11.2). Themes identified included the abstinence length, abstinence reason, relapse, triggers, time of relapse, and treatment. The most common code for abstinence length was "between 1 and 5 years" (n = 55, 35.9%). Other abstinence length codes included "less than 1 year" and "more than 5 years." Relapse triggers included "family (non-death)," "death of a loved one," "social," "economic," and "treatment-related" reasons. Findings from this study could be used to inform strategies for peer support interventions to assist patients with substance abstinence.

The Health Humanities and Emergency Medical Services (EMS): A Call to Action.

In the context of an on-going global pandemic that has demanded increasingly more of our Emergency Medical Services (EMS) clinicians, the health humanities can function to aid in educational training, promoting resilience and wellness, and allowing opportunity for self-expression to help prevent vicarious trauma.As the social, cultural, and political landscape of the United States continues to require an expanded scope of practice from our EMS clinicians, it is critical that the health humanities are implemented as not only part of EMS training, but also as part of continued practice in order to ensure the highest quality patient-centered care while protecting the longevity and resilience of EMS clinicians.

Factors related to substance use treatment attendance after peer recovery coach intervention in the emergency department.

Introduction: Brief intervention with peer recovery coach support has been used to generate referrals to substance use disorder treatment from the emergency department (ED). This retrospective study evaluated factors associated with successful linkage to treatment following brief intervention in the ED. Methods: Data were extracted from the electronic health record for patients who were referred to substance use treatment from the ED and for whom follow-up data regarding treatment attendance was available (n=666). We examined associations between demographic and insurance variables, substance use, mental health diagnosis, prior abstinence, and stage of change with successful linkage to substance use treatment after ED referral. Results: The sample was majority male (68%), White (62%), and had a mean age of 43 years (SD=12). Medicaid was the most common insurance (49%) followed by employer/private (34%). Multivariable logistic regression determined patients with Medicaid (OR=2.94, 95% CI:2.09-4.13, p=<.001), those who had a documented alcohol use disorder diagnosis (OR=1.59, 95% CI:1.074-2.342, p=.02), and those in the "Action" stage of change (OR=2.33, 95% CI:1.47-3.69, p=<.001) had greater odds of being successfully linked to treatment. Conclusions: These results identify characteristics of patients available in the health record to determine who is more likely or less likely to attend substance use treatment following ED referral. Given appropriate screening, this information could be used to direct standard care resources to those with high likelihood of treatment attendance and strengthen follow-up interventions with peer recovery coaches for those with lower likelihood of treatment attendance.

Racial and ethnic disparities in hospital observation in Maryland.

OBJECTIVES: Hospital observation is a key disposition option from the emergency department (ED) and encompasses up to one third of patients requiring post-ED care. Observation has been associated with higher incidence of catastrophic financial costs and has downstream effects on post-discharge clinical services. Yet little is known about the non-clinical determinants of observation assignment. We sought to evaluate the impact of patient-level demographic factors on observation designation among Maryland patients. METHODS: We conducted a retrospective analysis of all ED encounters in Maryland between July 2012 and January 2017 for four priority diagnoses (heart failure, chronic obstructive pulmonary disease [COPD], pneumonia, and acute chest pain) using multilevel logistic models allowing for heterogeneity of the effects across hospitals. The primary exposure was self-reported race and ethnicity. The primary outcome was the initial status assignment from the ED: hospital observation versus inpatient admission. RESULTS: Across 46 Maryland hospitals, 259,788 patient encounters resulted in a disposition of inpatient admission (65%) or observation designation (35%). Black (adjusted odds ratio [aOR]: 1.19; 95% confidence interval [CI]: 1.16-1.23) and Hispanic (aOR: 1.11; 95% CI: 1.01-1.21) patients were significantly more likely to be placed in observation than white, non-Hispanic patients. These differences were consistent across the majority of acute-care hospitals in Maryland (27/46). CONCLUSION: Black and Hispanic patients in Maryland are more likely to be treated under the observation designation than white, non-Hispanic patients independent of clinical presentation. Race agnostic, time-based status assignments may be key in eliminating these disparities.

Assessment of Physician Self-reported Knowledge and Use of Maryland's Extreme Risk Protection Order Law.

Importance: On October 1, 2018, Maryland's extreme risk protection order (ERPO) law took effect. This was the first ERPO law in the United States to authorize clinicians to initiate a civil court process to temporarily prohibit people behaving dangerously and at risk of engaging in violence from purchasing and possessing firearms. This is the first publication reporting results from a survey of physicians about ERPOs. Objectives: To assess Maryland physicians' knowledge, past use, and likely future use of ERPOs, and to identify barriers to physicians' use of ERPOs and strategies to address those barriers. Design, Setting, and Participants: This survey study conducted at The Johns Hopkins Hospital in Baltimore, Maryland, surveyed physicians, including emergency medicine physicians, pediatricians, and psychiatrists, using a 15-question online instrument between June 15, 2019, and July 1, 2019. Data analysis was performed in July 2019. Exposure: Maryland's ERPO law. Main Outcomes and Measures: Knowledge, use, and likely use of ERPOs, barriers to use, and strategies to address those barriers. Results: Ninety-two of 353 physicians invited (26.1%) completed the survey; 1 respondent reported having filed an ERPO petition. Sixty-six respondents (71.7%) described themselves as not at all familiar with ERPOs. After reading a brief description of the ERPO law, 85 respondents (92.4%) indicated that they encounter patients whom they would consider for an ERPO at least a few times per year. Fifty-five respondents (59.8%) reported that they would be very or somewhat likely to file an ERPO petition when they identify a qualifying patient. Respondents identified time as the main barrier to using ERPOs (not enough time to complete paperwork, 57 respondents [62.6%]; not enough time to attend hearing at courthouse, 64 respondents [70.3%]), followed by concern that filing an ERPO would negatively affect their relationship with the patient (36 respondents [39.6%]). Having a coordinator to manage the process (80 respondents [87.0%]), training (79 respondents [85.9%]), participating in court hearings remotely (68 respondents [73.9%]), and having access to legal counsel (59 respondents [64.1%]) were all selected by large majorities of respondents as strategies to address barriers to ERPO use. Conclusions and Relevance: Awareness of ERPOs among physicians in the sample was low. Physicians are treating patients who would qualify for an ERPO, and respondents in the sample indicated a willingness to use ERPOs. Training, providing access to legal counsel, designating a clinician to process petitions, and allowing clinicians to participate remotely in court hearings were strategies respondents identified to address barriers to ERPO use. These survey findings identify concrete solutions for addressing barriers to physician use of ERPOs.

Concept Mapping: Engaging Urban Men to Understand Community Influences on Partner Violence Perpetration.

Intimate partner violence (IPV) is a significant health concern rooted in community experiences and other social determinants. The purpose of this study is to understand community-based risk and protective factors of IPV perpetration through participatory research that engages men who use IPV. Secondarily, we assess the relative influence, as measured by ranking, of these factors regarding risk of IPV perpetration and stress. We conducted concept mapping with Baltimore men (n = 28), ages 18 and older, enrolled in an abuse intervention program (AIP), through partnership with a domestic violence agency. Concept mapping, a three-phase participatory process, generates ideas around an issue then visually presents impactful domains via multi-dimensional scaling and hierarchical clustering. Most participants were Black (87.5%) and 20-39 years old (75%). Seven key domains, or clusters, were established. "No hope for the future" was the greatest contributor to IPV perpetration. "Socioeconomic struggles" (i.e., lack of employment) and "life in Baltimore" (i.e., homicide) were most likely to result in stress. Emergent domains related to IPV perpetration and stress were ranked similarly, but with some nuance. Having good support systems (i.e., family, community centers) were felt to prevent IPV and reduce stress. This participant-driven process among a primarily young, Black sample of Baltimore men speaks to the influence of perceived social disempowerment and underlying trauma on intimate relationships and the potential for mitigation. Few studies have engaged men who use IPV through participatory research to understand the comprehensive dynamics of an impoverished, urban environment. Results provide direction for community-based intervention and prevention programming to increase self-efficacy, particularly among younger men, and to enact trauma-informed violence prevention policy from the perspectives of male IPV perpetrators.

Low rate of syphilis screening among high-risk emergency department patients tested for gonorrhea and chlamydia infections.

BACKGROUND: Implementing national recommendations for syphilis screening is not feasible in the emergency department (ED) setting. The purpose of this study was to determine the syphilis screening rate among ED patients tested for gonorrhea and chlamydia (GC/CT) and the syphilis prevalence among those who were tested. METHODS: A 1-year retrospective cohort study in an urban ED. At the time of this study, there were no explicit syphilis screening guidelines and testing was at the discretion of the treating physician. We determined the proportion of all GC/CT-tested patients who also underwent syphilis screening and the prevalence of syphilis among this group. Predictors of syphilis screening among patients tested for GC/CT were identified. RESULTS: GC/CT tests were performed in 3951 (4.7%) of the 83,988 ED visits, of which 332 (8.4%) were reactive. The mean age of GC/CT-tested patients was 22.6 ± 12 years, most were female (67%), black (47%), and English speaking (74%). Syphilis screening was completed in 1218 (31%) of the GC/CT-tested patients, 17 tests (1.4%) were reactive, which included 8 (0.7%) unique patients with newly diagnosed syphilis. In multivariable analysis, the following variables were predictive of syphilis screening: empirical GC/CT treatment (odds ratio [OR]: 1.9, 95% confidence interval [CI]: 1.6-2.3), evaluation in the low acuity section of the ED (OR: 1.8, 95% CI: 1.4-2.3), a reactive GC/CT test (OR: 1.3, 95% CI: 1.0-1.6), and age ≤25 years (OR: 1.2, 95% CI: 1.0-1.4). CONCLUSION: Among ED patients tested for GC/CT, less than one-third were screened for syphilis. Failure to screen these patients likely resulted in missed opportunities for syphilis diagnosis.