Outcomes After a Statewide Policy to Improve Evidence-Based Treatment of Back Pain Among Medicaid Enrollees in Oregon.

BACKGROUND: A novel Oregon Medicaid policy guiding back pain management combined opioid restrictions with emphasis on non-opioid and non-pharmacologic therapies. OBJECTIVE: To examine the effect of the policy on prescribing, health outcomes, and health service utilization. DESIGN: Using Medicaid enrollment, medical and prescription claims, prescription drug monitoring program, and vital statistics files, we analyzed the policy's association with selected outcomes using interrupted time series models. SUBJECTS: Adult Medicaid patients with back pain enrolled between 2014 and 2018. INTERVENTION: The Oregon Medicaid back pain policy. MAIN MEASURES: Opioid and non-opioid medication prescribing, procedural care, substance use and mental health conditions, and outpatient and inpatient healthcare utilization. KEY RESULTS: The policy was associated with decreases in the percentage of Medicaid enrollees with back pain receiving any opioids (- 2.68 percentage points [95% CI - 3.14, - 2.23] level, - 1.01 pp [95% CI - 1.1, - 0.92] slope), days of short-acting opioid use (- 0.4 days [95% CI - 0.53, - 0.26] slope), receipt of more than 7 days of short-acting opioids (- 2.36 pp [95% CI - 2.76, - 1.95] level, - 0.91 pp [95% CI - 1, - 0.83] slope), chronic opioid use (- 1.27 pp [95% CI - 1.59, - 0.94] level, - 0.46 [95% CI - 0.53, - 0.39 slope), and spinal surgeries and procedures. Among secondary outcomes, we found no increase in opioid overdose and a small, statistically significant trend decrease in opioid use disorders. There were small increases in non-opioid substance use and mental health diagnoses and visits but no increase in self-harm. CONCLUSIONS: A state Medicaid policy emphasizing evidence-based back pain management was associated with decreases in opioid prescribing, spinal surgeries, and opioid use disorder trends, but also short-term increases in mental health encounters and an increase in non-opioid substance use disorder trends. Such policies may help reinforce evidence-based care, but must be designed with consideration of potential harms.

Proceedings from the 2021 SAEM Consensus Conference: Research Priorities for Interventions to Address Social Risks and Needs Identified in Emergency Department Patients.

INTRODUCTION: Emergency departments (ED) function as a health and social safety net, regularly taking care of patients with high social risk and need. Few studies have examined ED-based interventions for social risk and need. METHODS: Focusing on ED-based interventions, we identified initial research gaps and priorities in the ED using a literature review, topic expert feedback, and consensus-building. Research gaps and priorities were further refined based on moderated, scripted discussions and survey feedback during the 2021 SAEM Consensus Conference. Using these methods, we derived six priorities based on three identified gaps in ED-based social risks and needs interventions: 1) assessment of ED-based interventions; 2) intervention implementation in the ED environment; and 3) intercommunication between patients, EDs, and medical and social systems. RESULTS: Using these methods, we derived six priorities based on three identified gaps in ED-based social risks and needs interventions: 1) assessment of ED-based interventions, 2) intervention implementation in the ED environment, and 3) intercommunication between patients, EDs, and medical and social systems. Assessing intervention effectiveness through patient-centered outcome and risk reduction measures should be high priorities in the future. Also noted was the need to study methods of integrating interventions into the ED environment and to increase collaboration between EDs and their larger health systems, community partners, social services, and local government. CONCLUSION: The identified research gaps and priorities offer guidance for future work to establish effective interventions and build relationships with community health and social systems to address social risks and needs, thereby improving the health of our patients.

"Community engagement via restorative justice to build equity-oriented crisis standards of care".

The COVID-19 (SARS-CoV-2) Pandemic has revealed multiple structural inequities within the United States (US), with high social vulnerability index communities shouldering the brunt of death and disability of this pandemic. BIPOC/Latinx people have undergone hospitalizations and death at magnitudes greater than White people in the US. The untold second casualties are health care workers that are suffering from increased risk of infection, death, and mental health crisis. Many health care workers are abandoning the profession all together. Although Crisis Standards of Care (CSC) mean to guide the ethical allocation of scare resources, they frequently use scoring systems that are inherently biased. This raises concern for the application of equity in CSC. Data examining the impact of these protocols on health equity is scarce. Structural maltreatment in healthcare and inequities have led to cumulative harms, physiologic weathering and structural adversities for residents of the US. We propose the use of Restorative Justice (RJ) practices to develop CSC rooted in inclusion and equity. The RJ framework utilizes capacity building, circle process, and conferences to convene groups in a respectful environment for dialogue, healing, accountability, and action plan creation. A phased, non-faith-based facilitated RJ approach for CSC development (or revision) that fosters ethically equitable resource distribution, authentic community engagement, and accountability is shared. This opportunity for local, inclusive decision making and problem solving will both reflect the needs and give agency to community members while supporting the dismantling of structural racism and oppressive, exclusive policies. The authors are asking legislative and health system policy makers to adopt Restorative Justice practices for Crisis Standards of Care development. The US cannot afford to have additional reductions in inhabitant lifespan or the talent pool within healthcare.

Description and productivity of emergency medicine researchers receiving K23 or K08 mentored research career development awards.

OBJECTIVES: The primary individual research career development awards for emergency medicine (EM) investigators are the K08 and K23 awards. To the best of the authors' knowledge, postaward productivity of EM K08 and K23 awardees has not been previously described. The objectives were to describe EM researchers who have received K08 or K23 awards and to evaluate their postaward federal funding and publications. METHODS: This was a cross-sectional study, conducted during January 2012, of clinician-scientists who previously completed EM residency or fellowship programs and have received K08 or K23 awards from the National Institutes of Health (NIH) or Agency for Healthcare Research and Quality (AHRQ) between fiscal years 2000 through 2011. Awardees were identified through the NIH reporting tool (NIH RePORTER). Postaward funding was abstracted, including R01-equivalent funding for K awardees who completed their K training by the end of the 2011 fiscal year. Postaward publications (with journal impact factor) were tabulated for all K awardees using PubMed and Journal Citation Reports. An e-mail survey was also conducted during September and October 2012 to describe the awardee characteristics (demographics and research background) of all EM K awardees using REDCap electronic data captures tools. Simple descriptive statistics are reported. RESULTS: Sixty-three EM awardees were identified; 24 (38%) were K08 awardees, and 39 (62%) were K23 awardees. Of the 38 (60%) awardees who completed their K training, 16 (42%) obtained subsequent federal funding, with six (16%) obtaining R01 funding (median time from end of K award to R01 award was 4.5 years). Overall, EM awardees published a mean (±SD) of 4.0 (±1.3) manuscripts per year (after the start of their K awards); the mean (±SD) impact factor of the journals in which these manuscripts were published was 4.5 (±5.7). Forty-five (71%) of EM K awardees responded to the survey. Respondents had a median age of 36 years (interquartile range [IQR] = 35 to 38 years), and 33 were male (73%). The median time from completion of residency to start of the K award was 6 years (IQR = 4 to 7 years), with 27 (60%) completing a research fellowship prior to the K award. CONCLUSIONS: Over 40% of EM K awardees who completed their career development training subsequently obtained federal funding as principal investigator (PI) or co-PI, while approximately one in six obtained R01 equivalent funding. Given the numerous barriers facing emergency care researchers, EM K awardees demonstrate good postaward productivity.