2023 Inaugural Healthcare Delivery Science: Innovation and Partnerships for Health Equity Research (DESCIPHER) Symposium.

Introduction: This article provides an overview of presentations and discussions from the inaugural Healthcare Delivery Science: Innovation and Partnerships for Health Equity Research (DESCIPHER) Symposium. Methods: The symposium brought together esteemed experts from various disciplines to explore models for translating evidence-based interventions into practice. Results: The symposium highlighted the importance of disruptive innovation in healthcare, the need for multi-stakeholder engagement, and the significance of family and community involvement in healthcare interventions. Conclusions: The article concluded with a call to action for advancing healthcare delivery science to achieve health equity.

Choosing Wisely interventions to reduce antibiotic overuse in the safety net.

OBJECTIVES: Physician pay-for-performance (P4P) programs frequently target inappropriate antibiotics. Yet little is known about P4P programs' effects on antibiotic prescribing among safety-net populations at risk for unintended harms from reducing care. We evaluated effects of P4P-motivated interventions to reduce antibiotic prescriptions for safety-net patients with acute respiratory tract infections (ARTIs). STUDY DESIGN: Interrupted time series. METHODS: A nonrandomized intervention (5/28/2015-2/1/2018) was conducted at 2 large academic safety-net hospitals: Los Angeles County+University of Southern California (LAC+USC) and Olive View-UCLA (OV-UCLA). In response to California's 2016 P4P program to reduce antibiotics for acute bronchitis, 5 staggered Choosing Wisely-based interventions were launched in combination: audit and feedback, clinician education, suggested alternatives, procalcitonin, and public commitment. We also assessed 5 unintended effects: reductions in Healthcare Effectiveness Data and Information Set (HEDIS)-appropriate prescribing, diagnosis shifting, substituting antibiotics with steroids, increasing antibiotics for ARTIs not penalized by the P4P program, and inappropriate withholding of antibiotics. RESULTS: Among 3583 consecutive patients with ARTIs, mean antibiotic prescribing rates for ARTIs decreased from 35.9% to 22.9% (odds ratio [OR], 0.60; 95% CI, 0.39-0.93) at LAC+USC and from 48.7% to 27.3% (OR, 0.81; 95% CI, 0.70-0.93) at OV-UCLA after the intervention. HEDIS-inappropriate prescribing rates decreased from 28.9% to 19.7% (OR, 0.69; 95% CI, 0.39-1.21) at LAC+USC and from 40.9% to 12.5% (OR, 0.72; 95% CI, 0.59-0.88) at OV-UCLA. There was no evidence of unintended consequences. CONCLUSIONS: These real-world multicomponent interventions responding to P4P incentives were associated with substantial reductions in antibiotic prescriptions for ARTIs in 2 safety-net health systems without unintended harms.

Providing Low-barrier Addiction Treatment Via a Telemedicine Consultation Service During the COVID-19 Pandemic in Los Angeles, County: An Assessment 1 Year Later.

BACKGROUND: Los Angeles County Department of Health Services provides medical care to a diverse group of patients residing in underresourced communities. To improve patients' access to addiction medications during the COVID-19 pandemic, Los Angeles County Department of Health Services established a low-barrier telephone service for DHS providers in March 2020, staffed by DATA-2000-waivered providers experienced with prescribing addiction medications. This study describes the patient population and medications prescribed through this service during its initial 12 months. METHODS: We performed a retrospective evaluation of a provider-entered call registry for the telephone consult line. Information was collected between March 31, 2020, and March 30, 2021. The registry includes information related to patient demographics, the reason for visit, and which addiction medications were prescribed. We conducted descriptive statistics in each of these domains. RESULTS: During the study period, 11 providers on the MAT telephone service logged 713 calls. These calls represented a total of 557 unique patients (mean age of 40 years, 75% male, 41% Latino, 49% experiencing homelessness). Most patients either had Medicaid insurance (77%) or were uninsured (20%). The most prescribed addiction medication was buprenorphine-naloxone (90%), followed by nicotine replacement therapy (5.3%), naltrexone (4.2%), and buprenorphine monotherapy (1.8%). CONCLUSION: A telephone addiction medication service is feasible to deliver low-barrier medications to treat addiction in underresourced communities, especially to individuals experiencing homelessness. This can mitigate but does not eliminate disparities in access to addiction medications for communities of color.

Effect of Didactic Training on Barriers and Biases to Treatment of Opioid Use Disorder: Meeting the Ongoing Needs of Patients with Opioid Use Disorder in the Emergency Department during the COVID-19 Pandemic.

In the wake of COVID-19, morbidity and mortality due to Opioid Use Disorder (OUD) is beginning to emerge as a second wave of deaths of despair. Medication assisted treatment (MAT) for opioid use disorder MAT delivered by Emergency Medicine (EM) providers can decrease mortality due to OUD; however, there are numerous cited barriers to MAT delivery. We examined the impact of MAT training on these barriers among EM residents in an urban, tertiary care facility with a large EM residency. Training included the scripted and standardized content from the Provider Clinical Support System curriculum. Residents completed pre- and post-training surveys on knowledge, barriers, and biases surrounding OUD. We performed Wilcoxon matched-pairs signed-ranks test to detect statistical differences. Of 74 residents, 49 (66%) completed the pre-training survey, and 34 (69%) of these completed the follow-up survey. Residents reported improved preparedness to treat aspects of OUD across all areas queried, reported decreased perception of barriers to providing MAT, and increased comfort prescribing naloxone, counseling patients, prescribing buprenorphine, and treating opioid withdrawal. A didactic training on MAT was associated with residents reporting improved comfort providing buprenorphine and naloxone. As the wake of morbidity and mortality from both COVID and OUD continue to increase, programs should offer dedicated training on MAT.

Buprenorphine and naloxone access in pharmacies within high overdose areas of Los Angeles during the COVID-19 pandemic.

BACKGROUND: Buprenorphine and naloxone are first-line medications for people who use opioids (PWUO). Buprenorphine can reduce opioid use and cravings, help withdrawal symptoms, and reduce risk of opioid overdose. Naloxone is a life-saving medication that can be administered to reverse an opioid overdose. Despite the utility of these medications, PWUO face barriers to access these medications. Downtown Los Angeles has high rates, and number, of opioid overdoses which could potentially be reduced by increasing distribution of naloxone and buprenorphine. This study aimed to determine the accessibility of these medications in a major urban city by surveying community pharmacies regarding availability of buprenorphine and naloxone, and ability to dispense naloxone without a prescription. METHODS: Pharmacies were identified in the Los Angeles downtown area by internet search and consultation with clinicians. Phone calls were made to pharmacies at two separate time points-September 2020 and March 2021 to ask about availability of buprenorphine and naloxone. Results were collected and analyzed to determine percentage of pharmacies that had buprenorphine and/or naloxone in stock, and were able to dispense naloxone without a prescription. RESULTS: Out of the 14 pharmacies identified in the downtown LA zip codes, 13 (92.9%) were able to be reached at either time point. The zip code with one of the highest rates of opioid-related overdose deaths did not have any pharmacies in the area. Most of the pharmacies were chain stores (69.2%). Eight of the 13 (61.5%) pharmacies were stocked and prepared to dispense buprenorphine upon receiving a prescription, and an equivalent number was prepared to dispense naloxone upon patient request, even without a naloxone prescription. All of the independent pharmacies did not have either buprenorphine or naloxone available. CONCLUSIONS: There is a large gap in care for pharmacies in high overdose urban zip codes to provide access to medications for PWUO. Unavailability of medication at the pharmacy-level may impede PWUO ability to start or maintain pharmacotherapy treatment. Pharmacies should be incentivized to stock buprenorphine and naloxone and encourage training of pharmacists in harm reduction practices for people who use opioids.

Changes in the availability of medications for opioid use disorder in prisons and jails in the United States during the COVID-19 pandemic.

BACKGROUND: During the COVID-19 pandemic, federal agencies relaxed buprenorphine prescribing restrictions including for incarcerated individuals. The impact of COVID-19 on the supply of MOUD in U.S. prisons and jails is not known. METHODS: We used cross-sectional national monthly data from the IQVIA National Sales Perspective (NSP) for the total volume of medicines supplied to city, county and state prisons and jails and other types of institutional facilities in the U.S. We measured the total monthly supply (or volume) as extended units (EUs) for MOUDs overall and by type. We used interrupted time series analysis to evaluate changes in monthly volume of MOUDs in prisons and jails and other types of facilities (hospitals, clinics and long-term care) before (January 2018-February 2020) and during the COVID-19 (March 2020-October 2020) pandemic. RESULTS: The availability of MOUD in jails and prisons increased by 471.3% between January 2018 (52,784 EU) and October 2020 (333,226 EU). This increase was largely driven by increased volume of buprenorphine/naloxone and was not observed in other institutional facilities, including hospitals, clinics and long-term care, and. Specifically, the mean monthly volume of buprenorphine/naloxone at prisons/jails increased every month before the pandemic by 1860 EU (95% CI, 1110-2360). In March 2020, the mean volume of buprenorphine/naloxone increased by 81,930 EU (95% CI, 59,040-104,820) per month, followed by a significant increase of 24,010 EU (95% CI 19,530-28,490) per month during the pandemic vs before the pandemic. CONCLUSION: These findings may indicate increased availability of buprenorphine/naloxone, a safe and effective MOUD, in prisons and jails since the start of the COVID-19 pandemic in the U.S. despite previous barriers in its use.

Medical Students' Knowledge and Attitudes Regarding Justice-Involved Health.

Despite the demonstrated need for sustainable and effective carceral health care, justice-involved medical education curricula are limited, and it's unclear if informal clinical education is sufficient. Investigators aimed to quantify medical student involvement with carceral populations and explore how students' knowledge of and attitudes towards justice-involved patients changed over the course of their training. A survey was designed by the investigators and sent to all current medical students at a single United States medical school. Stata 14.0 was used to compare results between the years of medical school. Differences between groups were tested using linear regression. Most 4th year students reported working in a carceral health setting. An increase in overall knowledge of justice-involved patients was observed as carceral medicine education (ptrend = 0.02), hours worked in a jail (ptrend < 0.01), and substance abuse training (ptrend < 0.01) increased. Overall attitude score increased with the students' reported number of hours working in a jail (ptrend < 0.01) and the amount of substance abuse training (ptrend < 0.01). Finally, we found a trend of increasing knowledge and attitude scores as the year of standing increased (ptrend < 0.01). Our data suggest that most USC medical students work in a carceral setting during medical school. Didactic and experiential learning opportunities correlated with improved knowledge of and attitude toward justice-involved patients, with increases in both metrics increasing as the year in medical school increased. However, senior medical students still scored poorly. These findings underscore the need for a formal curriculum to train our healthcare workforce in health equity for carceral populations.

Prevalence and distribution of high-risk prescription opioid use in the United States, 2011-2016.

PURPOSE: Despite the efforts of many stakeholders to reduce the risk of opioid overdose, there is limited information on the prevalence of high-risk prescription opioid use in the US. METHODS: Descriptive analysis of a nationally representative 5% random sample of anonymized, longitudinal, individual-level prescription claims from IQVIA LRx between January 1, 2011 and December 31, 2016 among individuals ages 18 years or older that used a retail pharmacy. High-risk opioid use was defined as ≥50 morphine milligram equivalents per day and/or having concurrent dispensing of a benzodiazepine based on overlapping days of coverage. RESULTS: The prevalence of high-risk opioid use among adults in the US decreased from 12.0% in 2011 to 9.4% in 2016 (p < 0.01). Declines were most pronounced among individuals ages 18-35 years (10.9%-7.0%, 36.2% decline; p < 0.01) compared to individuals age 65 years or greater (10.5%-9.8%, 6.7% decline; p < 0.01). Declines in high-risk use prevalence were observed across 49 states, with only South Dakota experiencing an increase (+13.7% relative increase). Similar to earlier years, in 2016 50.9% of all high-risk use opioid users received all their opioid prescriptions from a single prescriber, and 71.1% used a single pharmacy to fill them. CONCLUSION: Despite clinically significant declines in high-risk opioid use, in 2016 nearly 1 in 10 adult retail pharmacy users remained at high-risk for opioid overdose in the US. Future clinical and policy interventions should consider targeting older adults with Medicare Part-D, including those using a single pharmacy to fill their opioid prescriptions.

Pharmacist-Prescribed And Over-The-Counter Hormonal Contraception In Los Angeles County Retail Pharmacies.

Federal and state policies to increase access to birth control have included expanding access to preventive and emergency hormonal contraception at pharmacies for women and girls of all ages without a physician's prescription. We conducted a "mystery shopper" telephone survey to quantify the impact of these policies in Los Angeles County, California. That county consistently has among the highest number of unintended pregnancies and teen births in the US, especially in low-income and minority neighborhoods. Between June and November 2017, three in four pharmacies offered over-the-counter emergency hormonal contraception, but only one in ten offered pharmacist-prescribed preventive hormonal contraception. Many of these pharmacies also imposed age restrictions when dispensing hormonal contraception, including in the neighborhoods at highest risk for unintended pregnancies and teen births, even though the Food and Drug Administration removed age restrictions for over-the-counter emergency hormonal contraception in 2013. In addition, many low-income, minority neighborhoods lacked pharmacies when the survey was performed. Policies aimed solely at expanding pharmacy access to birth control might not be sufficient to address disparities in contraceptive use.

Organizational factors associated with practitioners' support for treatment of opioid use disorder in the emergency department.

BACKGROUND: Despite the significant increase in emergency room visits for opioid overdose, only few emergency departments (ED) have implemented best practices to treat people with opioid use disorders (OUD). Some implementation gaps may be due to practitioner factors; such as support for medication-assisted treatment (MAT) for OUD in the ED. In this study, we explore the relationship between inner setting characteristics of the EDs (e.g., leadership, readiness for change, organizational climate) and practitioner support for OUD treatment and attitudes towards people with OUD. METHODS: We surveyed 241 ED practitioners (e.g., physicians, nurses, social workers) at one of the largest EDs in the United States. We used analysis of variance and chi-square global tests to compare responses from ED practitioners in differing roles. We also conducted five multivariate logistic regressions to explore associations between ED inner setting characteristics and five antecedents of implementation; ED practitioner (1) supports MAT for OUD in the ED, (2) supports best practices to treat OUD, (3) has self-efficacy to treat OUD, (4) has stereotypes of people who use drugs, and (5) has optimism to treat people with OUD. RESULTS: We found nurses were more likely than physicians to support MAT for OUD in the ED and delivering other best practices to treat OUD. At the same time, nurses had greater bias than physicians against working with patients suffering from OUD. We also found the ED's climate for innovation and practitioners' readiness for change were positively associated with support for MAT for OUD in the ED and using best practices to treat OUD. CONCLUSIONS: Findings suggest that professional roles and some ED inner setting factors play an important role in antecedents of implementation of OUD treatment in the ED. To prepare EDs to effectively respond to the current opioid overdose epidemic, it is critical to further understand the impact of these organizational factors on the implementation of evidence-based OUD treatment practices in the nation.

Undocumented Patients in the Emergency Department: Challenges and Opportunities.

In the United States, undocumented residents face unique barriers to healthcare access that render them disproportionately dependent on the emergency department (ED) for care. Consequently, ED providers are integral to the health of this vulnerable population. Yet special considerations, both clinical and social, generally fall outside the purview of the emergency medicine curriculum. This paper serves as a primer on caring for undocumented patients in the ED, includes a conceptual framework for immigration as a social determinant of health, reviews unique clinical considerations, and finally suggests a blueprint for immigration-informed emergency care.

Building Immigration-Informed, Cross-Sector Coalitions: Findings from the Los Angeles County Health Equity for Immigrants Summit.

In December 2017, the Los Angeles County Office of Immigrant Affairs and Board of Supervisors, alongside local health care and legal providers, convened the Health Equity for Immigrants and Families Summit to advance a vision for immigrant health. We describe the four critical concepts identified by stakeholders to address the varied needs of immigrants in an increasingly anti-immigrant political environment: (1) Recognizing immigration status as a modifiable social determinant of health; (2) Adopting the concept of "Immigration-Informed Care" within health care institutions; (3) Establishing immigration-focused medical-legal partnerships; and (4) Building coordinated systems based on knowledge of local stakeholders, policies, and funding mechanisms.

Availability and Cost of Naloxone Nasal Spray at Pharmacies in Philadelphia, Pennsylvania, 2017.

Importance: Despite the increasingly important role of pharmacies in the implementation of naloxone access laws, there is limited information on the impact of such laws at the local level. Objective: To evaluate the availability (with or without a prescription) and cost of naloxone nasal spray at pharmacies in Philadelphia, Pennsylvania, following a statewide standing order enacted in Pennsylvania in August 2015 to allow pharmacies to dispense naloxone without a prescription. Design, Setting, and Participants: A survey study was conducted by telephone of all pharmacies in Philadelphia between February and August 2017. Pharmacies were geocoded and linked with the American Community Survey (2011-2015) to obtain information on the demographic characteristics of census tracts and the Medical Examiner's Office of the Philadelphia Department of Public Health to derive information on the number of opioid overdose deaths per 100 000 people for each planning district. Data were analyzed from March 2018 to February 2019. Main Outcomes and Measures: Availability and out-of-pocket cost of naloxone nasal spray (with or without a prescription) at Philadelphia pharmacies overall and by pharmacy and neighborhood characteristics. Results: Of 454 eligible pharmacies, 418 were surveyed (92.1% response rate). One in 3 pharmacies (34.2%) had naloxone nasal spray in stock; of these, 61.5% indicated it was available without a prescription. There were significant differences in the availability of naloxone by pharmacy type and neighborhood characteristics. Naloxone was both more likely to be in stock (45.9% vs 27.8%; difference, 18.0%; 95% CI, 8.3%-27.8%; P < .001) and available without a prescription (80.6% vs 42.2%; difference, 38.4%; 95% CI, 23.0%-53.8%; P < .001) in chain stores than in independent stores. Naloxone was also less likely to be available in planning districts with very elevated rates of opioid overdose death (≥50 per 100 000 people) compared with those with lower rates (31.1% vs 38.5%). The median (interquartile range) out-of-pocket cost among pharmacies offering naloxone without a prescription was $145 ($119-$150); costs were greatest in independent pharmacies and planning districts with elevated rates of opioid overdose death. Conclusions and Relevance: Despite the implementation of a statewide standing order in Pennsylvania more than 3 years prior to this study, only one-third of Philadelphia pharmacies carried naloxone nasal spray and many also required a physician's prescription. Efforts to strengthen the implementation of naloxone access laws and better ensure naloxone supply at local pharmacies are warranted, especially in localities with the highest rates of overdose death.