Multidisciplinary treatment of opioid use disorder in primary care using the collaborative care model.

Background: Treatment of opioid use disorder (OUD) is highly effective, but access is limited and care is often fragmented. Treatment in primary care can improve access to treatment and address psychiatric and physical co-morbidities in a holistic, efficient, and non-stigmatizing way. The Collaborative Care Model (CCM) of behavioral health integration into primary care has been widely disseminated and shown to improve outcomes and lower costs when studied for depression, but its use in treating substance use disorders has not been well documented. Methods: We used a mixed-methods approach to examine the impact of implementing multidisciplinary treatment of OUD in our health system's five primary care clinics using the framework of the CCM, with care shared between the primary care clinician (PCP), behavioral health clinician, and medical assistant. The implementation included staff education, creation of electronic health record tools, and implementation support, and was evaluated using data from the electronic health record, the medical staff office, and a clinician survey. Results: Over the last 2 years of implementation, the number of waivered providers increased from 11 to 35, providers prescribing for 5 or more patients increased from 2 to 18, and patients initiated on buprenorphine increased from 4/month to 18/month. 180-day treatment retention was 53%, and 81% of patients had consistently negative urine drug testing. Psychiatric and medical comorbidities were common, 70 and 44%, respectively. Although PCPs who prescribed buprenorphine found working in this model enjoyable and effective, the majority of non-waivered PCPs remained reluctant to participate. Conclusions: In our experience, treatment of OUD in primary care utilizing the CCM effectively addresses OUD and commonly comorbid anxiety and depression, and leads to an expansion of treatment. Successful implementation of OUD treatment requires addressing negative attitudes and perceptions.

Impact of numeracy on understanding of prostate cancer risk reduction in PSA screening.

Prostate-specific antigen (PSA) screening for prostate cancer in men of average risk remains controversial. Patients' ability to incorporate risk reduction data into their decision-making may depend on their numeracy. We assessed the impact of patients' numeracy on their understanding of the risk reduction benefits of PSA screening. Men attending a general internal medicine clinic were invited to complete a survey. Four versions of the survey each included a three-item numeracy test and PSA risk reduction data, framed one of four ways: absolute (ARR) versus relative risk reduction (RRR), with or without baseline risk (BR). Respondents were asked to adjust their perceived risk of prostate-cancer mortality using the data presented. Accuracy of risk reduction was evaluated relative to how risk data were framed. Among a total of 200 respondents, a majority incorrectly answered one or more of the numeracy items. Overall accuracy of risk adjustment was only 20%. Accuracy varied with data framing: when presented with RRR, respondents were 13% accurate without BR and 31% accurate with BR; when presented with ARR, they were 0% accurate without BR and 35% accurate with BR. Including BR data significantly improved accuracy for both RRR (P = 0.03) and ARR groups (P < 0.01). Accuracy was significantly related to numeracy; numeracy scores of 0, 1, 2, and 3 were associated with accuracy rates of six, five, nine, and 36 percent, respectively (P < 0.01). Overall, numeracy was significantly associated with the accuracy of interpreting quantitative benefits of PSA screening. Alternative methods of communicating risk may facilitate shared decision-making in the use of PSA screening for early detection of prostate cancer.

Responses to a Decision Aid on Prostate Cancer Screening in Primary Care Practices.

INTRODUCTION: Prostate-specific antigen (PSA) testing remains controversial, with most guidelines recommending shared decision making. This study describes men's PSA screening preferences before and after viewing a decision aid and relates these preferences to subsequent clinician visit content. METHODS: Men were recruited from two health systems in 2009-2013. Participants answered a questionnaire before and after decision aid viewing addressing PSA screening preferences and five basic knowledge questions. At one health system, participants also answered a survey after a subsequent clinician visit. Data were analyzed in 2014. RESULTS: One thousand forty-one predominantly white, well-educated men responded to the pre- and post-viewing questionnaire (25% and 29% response rates at the two sites). After viewing, the proportion of patients leaning away from PSA screening increased significantly (p<0.001), with 386 (38%) leaning toward PSA screening versus 436 (43%) before viewing; 174 (17%) unsure versus 319 (32%) before; and 448 (44%) leaning away versus 253 (25%) before. Higher knowledge scores were associated with being more likely to lean against screening and less likely to be unsure (p<0.001). Among 278 men who also completed a questionnaire after a subsequent clinician visit, participants who planned to discuss PSA screening with their clinicians were significantly more likely to report such discussions than participants who did not (148/217 [68%] vs 16/46 [35%], respectively [p<0.001]). CONCLUSIONS: A decision aid reduces men's interest in PSA screening, particularly among the initially unsure. Men who plan to discuss PSA screening with their clinician after a decision aid are more likely to do so.

Use of a web-based survey to facilitate shared decision making for patients eligible for cancer screening.

OBJECTIVE: Our aim was to facilitate shared decision making (SDM) during preventive visits by utilizing a web-based survey system to offer colorectal cancer (CRC) and prostate cancer screening decision aids (DAs) to appropriately identified patients prior to the visit. METHODS: Patients completed a web-based questionnaire before their preventive medicine appointment. Age- and gender-appropriate patients completed additional questions to determine eligibility for CRC or prostate-specific antigen (PSA) screening. Eligible patients were offered a choice of video or print DA, and completed questions assessing their knowledge, values, and preferences regarding the screening decision. Responses were summarized and fed forward to clinician and patient reports. RESULTS: Overall, 11,493 CRC and 4,384 PSA questionnaires were completed. Patient responses were used to identify those eligible for cancer-screening DAs: 2,187 (19 %) for CRC and 2,962 (68 %) for PSA; 15 % of eligible patients requested a DA. Many patients declined a DA because they indicated they "already know enough to make their decision" (34 % for CRC, 46 % for PSA). CONCLUSION: A web-based questionnaire provides an efficient means to identify patients eligible for cancer screening decisions and to offer them DAs before an appointment. Pre-visit use of DAs along with reports giving feedback to patients and clinicians provides an opportunity for SDM to occur at the visit.