Wellness Wheel Clinics: A First Nation community-partnered care model improving healthcare access, from healthcare providers' perspectives.

First Nation people residing in rural and remote communities have limited primary healthcare access, which often affects chronic disease management leading to poor health outcomes. Individuals with lived experiences of chronic disease and substance use, along with health directors, advocated for improved services. Subsequently, an urban healthcare team in partnership with four First Nation communities developed an Outreach clinic to address healthcare access barriers. Established in 2016, this community-led clinic improves primary care access and chronic disease management in First Nation communities. Employing a qualitative research design, interviews were conducted with 15 clinic providers and 9 community members to explore the clinic's 1-year post-implementation impacts. Thematic data analysis indicated that engagement and approval by community leadership, support from Elders and community members and collaboration with existing community healthcare staff were crucial for establishing the Outreach clinic. Initial logistical challenges with space allocation, equipment, medical supplies, funding, staffing, medical records and appointment scheduling were resolved through community consultation and creative solutions. A nurse coordinator ensured continuity of care and was integral to ensuring clients receive seamless care. The commitment of the outreach team and the collective goal of providing client-centered care were instrumental in the clinic's success. In partnership with communities, access to healthcare in First Nation communities can be enhanced by coordinating Outreach clinics through existing community healthcare facilities.

The Effect of Weather and Sporting Events on Ambulatory Visits and Hospitalizations at a Veterans Affairs Medical Center.

BACKGROUND: We explored the impact of weather and sporting events on clinic and emergency department (ED) visits and hospitalization. METHODS: Weather, dates of sporting events, ED visits, hospitalizations, clinic visits, no-shows, and same-day patient cancellations from 2015 to 2018 were abstracted from Milwaukee's Veterans Affairs (VA) medical system. RESULTS: Inclement precipitation increased clinic cancellations. Snowfall reduced ED visits. Green Bay Packer football games, University of Wisconsin-Madison football games, and the Super Bowl reduced ED visits but not hospitalizations. Milwaukee Brewers baseball home games didn't affect ED visits, but hospital admissions increased slightly. Basketball events (Milwaukee Bucks, University of Wisconsin-Madison, University of Wisconsin-Milwaukee, Marquette University) had no impact. CONCLUSION: Inclement weather increased clinic cancellations, and snow reduced ED visits. Football games reduced ED visits, while baseball increased hospitalizations, probably because the Milwaukee Brewers stadium is located on the VA property.

Risk Factors for Climate-Related Health Effects in an Ambulatory Population.

BACKGROUND: Climate change is a global health crisis. In most regions, heat waves are expected to become longer and more frequent and air quality is expected to worsen. Few physicians discuss climate and health with patients, and related guidelines are lacking. Our objective was to quantify the prevalence of risk factors for illness related to climate change in the U.S. ambulatory setting. METHODS: From the 2018 National Ambulatory Medical Care Survey, a national probability sample of nonfederal, ambulatory encounters, we identified adults with risk factors for illness related to heat or air pollution exposure. RESULTS: We found 91.4% of encounters involved a patient with at least 1 risk factor, while 46.7% had 2 or more. CONCLUSION: A high prevalence of patients with climate-related health risk factors exists in the ambulatory setting, representing a significant opportunity for evidence-based climate and health patient education and preventative care.

Faculty Physician and Trainee Experiences with Micro- and Macroaggressions: a Qualitative Study.

BACKGROUND: Micro- and macroaggressions are often stereotype threats that can have detrimental effects on the recipients. Survey data shows that these aggressions are happening. However, there are few qualitative studies on trainees and faculty physicians' experiences with such aggressions and their impact. OBJECTIVE: Explore how micro- and macroaggressions impact physician trainees and faculty. DESIGN, SETTING, PARTICIPANTS: Virtual, one-on-one, semi-structured interviews were conducted between February and September 2021, among 14 physicians and trainees (medical students, residents, fellows, and faculty) at a tertiary, urban, US academic medical center and its associated hospitals. Participants shared their experiences with micro- and macroaggressions in training and the workplace, as well as their thoughts on intervention and education. APPROACH: Qualitative interviews; grounded theory approach KEY RESULTS: A total of 14 physicians and trainees (5 faculty, 2 fellows, 5 residents, 2 students; 11 [79%] women) participated. Four themes with multiple subthemes surfaced: definition, the moment an aggression is experienced, aftereffect of an aggression, and education and training. While general definitions of micro- and macroaggressions were similar among participants, some may have overlooked the inclusion of a marginalized group as central to each term. Both types of aggressions had a range of effects on participants, with faculty noting a cumulative effect. Institutional diversity was identified as a key source of support. Ideas on how to combat such acts included mandatory educational programs and policies, with the acknowledgment that much effort and time are necessary to change mindset and culture. CONCLUSIONS: Faculty physicians and medical trainees shared their personal experiences with micro- and macroaggressions during work and training. Participants described various emotions in the moment but also noted that these aggressions often had lasting impacts. They recognized the challenges of finding a solution to micro- and macroaggressions. Institution-wide education was favored by many as a first step.

Sexual Harassment of Female Providers by Patients: a Qualitative Study.

BACKGROUND: Sexual harassment of women is a pervasive problem. Prior studies found that sexual harassment of female providers by patients is common, but guidance on addressing this problem is limited. OBJECTIVE: To understand the experiences of female providers with sexual harassment by patients with a focus on how practicing providers address these events. DESIGN: Qualitative study using semi-structured interviews. PARTICIPANTS: Twenty female, internal medicine providers, including resident physicians, staff physicians, and nurse practitioners at a large, urban, academic hospital in the USA. APPROACH: Interviews were analyzed for themes. KEY RESULTS: Two themes were explored: first, the experiences with sexual harassment and, second, the strategies to address sexual harassment. We coded four sub-themes regarding participant experiences: (1) their descriptions of the types of harassment, (2) the context of the event, (3) the impact of the harassment, and (4) their preparation to address the harassment. We coded seven sub-themes on strategies used by participants: (1) indirect strategies, (2) confrontation, (3) modifying the clinical encounter, (4) modifying self, (5) alerting others, (6) debrief, and (7) report. CONCLUSION: Our qualitative study found that sexual harassment of female providers by patients is an ongoing problem, disruptive to the patient-provider relationship, and a possible threat to the well-being of both provider and patient. Formal training on how to address this problem was lacking, but all providers had developed or adapted strategies based on personal experiences or role modeling. Educating providers on strategies is an important next step to addressing this problem.

The Experience of Male Physicians with Sexual and Gender-Based Harassment: a Qualitative Study.

BACKGROUND: Sexual harassment and gender-based harassment are common in medicine; however, there is little in the literature regarding men's experience with gender-based and sexual harassment. OBJECTIVE: The objective of this study was to better understand the experience men have with sexual and gender-based harassment in medicine. DESIGN: We developed and piloted an interview guide based on a review of the literature and conducted semi-structured interviews of male physicians, from trainees to attendings, at a tertiary care facility. Participants were recruited via email between April and August of 2019. These interviews were transcribed verbatim and, using an iterative coding approach based in grounded theory, were coded and analyzed for themes. MAIN RESULTS: We conducted a total of 16 interviews. Five major themes were identified: (1) personal experiences of harassment, (2) witnessed harassment, (3) characterization of harassment, (4) impact of harassment, and (5) strategies for responding to harassment. The men reported experiences with sexual and gender-based harassment but were hesitant to define these encounters as such. They had minimal emotional distress from these encounters but worried about their professional reputation and lacked training for how to respond to these encounters. Many had also witnessed their female colleagues being harassed by both male patients and colleagues but did not respond to or stop the harassment when it originated from a colleague. CONCLUSION: We found that men experience sexual harassment differently from women. Most notably, men report less emotional distress from these encounters and often do not define these events as harassment. However, similar to women, men feel unprepared to respond to episodes of harassment against themselves or others. Whether to deter sexual harassment against themselves, or, more commonly, against a female colleague, men can gain the tools to speak up and be part of the solution to sexual harassment in medicine.

Opioid Dose and Benzodiazepine Use Among Commercially Insured Individuals on Chronic Opioid Therapy.

OBJECTIVE: To examine morphine milligram equivalent (MME) trends, use of concurrent opioids and benzodiazepines, and opioid-related emergency department (ED) visits or hospitalizations in a national cohort of patients on chronic opioid therapy. DESIGN: Retrospective cohort analysis of prospectively collected data from the Truven Health MarketScan Commercial Claims and Encounters database from 2009 to 2015. This includes individuals in both the Commercial Claims and Medicare Supplemental databases of MarketScan. METHODS: MME comparisons of 1) patients on chronic opioids with and without opioid-related ED visits or hospitalizations, 2) patients on concurrent opioids and benzodiazepines with and without opioid-related ED visits or hospitalizations, and 3) patients on chronic opioids compared with those on concurrent opioid and benzodiazepine using the Student t test. RESULTS: MME decreased from 194 mg in 2009 to 119 mg in 2015 among patients on chronic opioids. Patients on opioids and benzodiazepines had higher doses than those on opioids alone for all years (P < 0.001). Those with an opioid-related ED visit or hospitalization had a higher average MME than those without, for all years except 2009 (P < 0.05). Patients on chronic opioids or on concurrent benzodiazepine with an MME >50 had a twofold increased risk of having an opioid-related ED visit or hospitalization compared with those with an MME <50, for all years. CONCLUSIONS: Although the average MME decreased over time, patients on combination opioid and benzodiazepine and those with opioid-related ED visits and hospitalizations had significantly higher doses.

Health care utilization by veterans prescribed chronic opioids.

PURPOSE: Ambulatory resources such as telephone calls, secure messages, nurse visits, and telephone triage are vital to the management of patients on chronic opioid therapy (COT). They are also often overlooked as health care services and yet to be broadly studied. The aim of the present study was to describe the Veterans Affairs (VA) health care utilization by patients based on COT, type, and amount of opioids prescribed. PATIENTS AND METHODS: A retrospective chart review was done on 617 patients on COT at a VA primary care clinic. Instances of health care utilization (emergency department visits [EDVs], hospitalizations, clinic visits, telephone triage calls, telephone calls/secure messages/nurse visits) were obtained. RESULTS: Patients were likely to have more telephone calls, secure messages, or nurse visits if they were prescribed a schedule II opioid or if they were on more than one opioid. Model-based results found that patients on COT were more likely to have EDVs, telephone triage calls, and clinic contact compared to patients who were not on chronic opioids. CONCLUSION: The results are despite having a Patient Aligned Care Team, which is the VA's patient-centered medical home. This suggests that reducing health care utilization for patients on COT may not be possible with just a primary care involvement.

Opioid-related Emergency Department Visits and Hospitalizations Among Commercially Insured Individuals, 2009-2015.

OBJECTIVES: Overall opioid prescribing rates have decreased since 2012, but opioid-involved deaths have not. This study describes the regional and overall trends of opioid-related emergency department visits (EDVs) and hospitalizations of commercially insured patients on chronic opioids and those on concurrent opioids and benzodiazepines. METHODS: Secondary data analysis from Truven Health MarketScan Commercial Claims and Encounters (MarketScan) database from 2009 to 2015 was used. Outcomes were geographic rates of opioid-related EDVs and hospitalizations and rates of concurrent benzodiazepine and opioid use. RESULTS: Rates of opioid-related EDVs and hospitalizations for patients on chronic opioids have decreased since 2009. Two thirds of those with opioid-related EDVs and nearly 3-quarters of those with an opioid-related hospitalization were coprescribed benzodiazepines. The North Central region had the highest proportion of individuals on chronic opioid therapy (2.7%) in 2015. However, the South had not only the highest rates of opioid-related EDVs (23/100,000 in 2015) and opioid-related hospitalizations (39/100,000 in 2015) but also the largest percentage of individuals on concurrent opioids and benzodiazepines (41%). DISCUSSION: Rates of opioid-related EDVs and hospitalizations, as well as concurrent opioid and benzodiazepine use, vary geographically. More research is needed to examine factors that impact regional variation and what influences the concurrent use of opioids and benzodiazepines.

Pain Agreements and Healthcare Utilization in a Veterans Affairs Primary Care Population: A Retrospective Chart Review.

INTRODUCTION: The prevalence of chronic pain is enormous. In America, the management of chronic pain and opioids remains a critical focus. Guidelines recommend pain agreements as part of the management of chronic pain and opioids; however, evidence of improvement in patient outcomes is lacking. An aspect of patient outcome includes utilization of healthcare resources, such as emergency department visits and hospitalizations. It remains uncertain whether the use of pain agreements lessens healthcare utilization. METHODS: Retrospective chart review of a Midwest Veterans Affairs primary care clinic. Subjects were veterans on chronic opioids between 1 April 2014 and 1 April 2015. Outcome measures included emergency department visits, hospitalizations, clinic visits, telephone triage, telephone/secure messages, and nurse visits. RESULTS: The charts of 635 veterans on chronic opioids were reviewed. Of these, 295 were on a pain agreement. There were no significant differences in demographics, medical, or psychiatric diagnoses between patients with and without pain agreements. There were significant differences in opioid schedule and number of opioids based on pain agreement (p < 0.01). Patients on pain agreements did not utilize healthcare resources less than patients without a pain agreement. In fact, patients on pain agreements were likely to have more telephone calls, secure messages, and nurse visits compared with patients not on an agreement (p = 0.02). CONCLUSIONS: Pain agreements are becoming standard of care for chronic pain management. However, there continues to be a lack of evidence demonstrating improvement in healthcare outcomes with their use, despite guideline recommendations. Further studies are needed to examine specific patient outcomes, such as overdose and death, in regard to pain agreements. FUNDING: Advancing a Healthier Wisconsin-Patient-Centered Outcomes Research Program.

Tricyclic and Tetracyclic Antidepressants for the Prevention of Frequent Episodic or Chronic Tension-Type Headache in Adults: A Systematic Review and Meta-Analysis.

BACKGROUND: Tension-type headaches are a common source of pain and suffering. Our purpose was to assess the efficacy of tricyclic (TCA) and tetracyclic antidepressants in the prophylactic treatment of tension-type headache. METHODS: We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, the ISI Web of Science, and clinical trial registries through 11 March 2017 for randomized controlled studies of TCA or tetracyclic antidepressants in the prevention of tension-type headache in adults. Data were pooled using a random effects approach. KEY RESULTS: Among 22 randomized controlled trials, eight included a placebo comparison and 19 compared at least two active treatments. Eight studies compared TCAs to placebo, four compared TCAs to selective serotonin reuptake inhibitors (SSRIs), and two trials compared TCAs to behavioral therapies. Two trials compared tetracyclics to placebo. Single trials compared TCAs to tetracyclics, buspirone, spinal manipulation, transcutaneous electrical stimulation, massage, and intra-oral orthotics. High-quality evidence suggests that TCAs were superior to placebo in reducing headache frequency (weighted mean differences (WMD): -4.8 headaches/month, 95% CI: -6.63 to -2.95) and number of analgesic medications consumed (WMD: -21.0 doses/month, 95% CI: -38.2 to -3.8). TCAs were more effective than SSRIs. Low-quality studies suggest that TCAs are superior to buspirone, but equivalent to behavioral therapy, spinal manipulation, intra-oral orthotics, and massage. Tetracyclics were no better than placebo for chronic tension-type headache. CONCLUSIONS: Tricyclic antidepressants are modestly effective in reducing chronic tension-type headache and are superior to buspirone. In limited studies, tetracyclics appear to be ineffective in the prophylactic treatment of chronic tension-type headache.

Utilization of Health Care Services and Ambulatory Resources Associated with Chronic Noncancer Pain.

OBJECTIVE: Examine traditional and uncompensated health care utilization associated with chronic noncancer pain. DESIGN: Retrospective chart review. SETTING: Tertiary academic medical center. SUBJECTS: Internal medicine patients on long-term opioids for chronic noncancer pain with or without a pain agreement between April 1, 2014, and April 1, 2015 (N = 834). Patients without pain served as controls (N = 782). METHODS: Univariate statistics were used to compare health care utilization by the presence of chronic pain, pain agreement status, opioid dose, and schedule. Logistic regression was used to assess predictors of health care utilization, with emergency room visits, hospitalizations, and after-hour calls as binary outcomes and office visits and phone/e-mail contacts as ordinal outcomes. RESULTS: Patients with chronic pain used significantly more health care resources compared with patients without pain (all P < 0.001). Patients on a pain agreement had more telephone and secure messages than patients without an agreement ( P = 0.002). Controlling for demographics and other factors, patients with chronic pain had 2.6 (95% confidence interval [CI] = 2.1-3.4) times the odds of an emergency room visit, 5.0 (95% CI = 3.6-7.0) times the odds of a hospitalization, and 2.3 (95% CI = 1.7-3.0) times the odds of an after hour call, compared with nonpain controls. Ordinal logistic regression yield adjusted common odds ratios of 3.4 (95% CI = 2.7-4.2) and 2.9 (95% CI = 2.3-3.6) for total clinic visits and telephone or secure messages, respectively, indicating higher utilization for chronic pain patients. CONCLUSIONS: Patients with chronic noncancer pain utilized more traditional and uncompensated health care resources compared with patients without chronic pain.

Adherence to chronic opioid therapy prescribing guidelines in a primary care clinic.

OBJECTIVE: Characterize primary care patients prescribed opioids for chronic noncancer pain (CNCP), explore guideline-recommended opioid-monitoring practices, and investigate predictors of pain agreements. DESIGN: Retrospective chart review. SETTING: Primary care clinic at a tertiary academic medical center. PATIENTS: Adults prescribed chronic opioids (three or more monthly prescriptions within a year) for CNCP between April 1, 2014 and April 1, 2015. Patients without CNCP served as controls. MAIN OUTCOME MEASURE: Patient demographics, medical diagnoses, tobacco status, provider status, documentation of guideline-recommended opioid-monitoring practices, pain agreement status, and opioid prescription. Univariate statistics were used to explore differences in patient demographics, comorbidities, and guideline-recommended opioid-monitoring practices by chronic pain and pain agreement status. Logistic regression was used to investigate predictors of agreement status. RESULTS: The clinic had 834 (9 percent) patients on chronic opioids, with 335 on a pain agreement. Documentation of opioid-monitoring practices was lacking. Logistic regression indicated that patients were significantly more likely to be on an agreement if they were Caucasian (adjusted odds ratio [OR] 2.17 [95% CI 1.41, 3.39]), had a baseline urine drug screen (adjusted OR 10.72 [95% CI 6.16, 19.41]), were prescribed a schedule II controlled medication (adjusted OR 11.92 [95% CI 6.93, 21.62]), and had risk assessed to some degree (adjusted OR 3.06 [95% CI 1.90, 4.96]). CONCLUSIONS: Aside from race, most patient characteristics were not predictive of pain agreement implementation. However, controlled medication of higher schedules and the use of certain guideline-recommended practices were associated with an agreement. Studies are needed to examine whether pain agreement or guideline-adherence influence clinical outcomes.