Older adults with communication disabilities and their use of communication support at doctor's visits: a nationally representative study.

PURPOSE: Older adults with communication disabilities (CDs) experience barriers to receiving care and face a paucity of accommodations for their disability. Utilizing someone that supports communication with healthcare providers (communication support persons) may be a way that this group self-supports their disability. We examined if this utilization was independently associated with CDs among older adults. We also sought to understand if socioeconomic factors were associated with utilization. METHODS: We used the 2015 National Health and Aging Trends Survey (NHATS) to conduct a cross-sectional analysis of Medicare beneficiaries (n = 5954) with functional hearing, expressive, or cognitive difficulties. We calculated a weighted, population prevalence and an adjusted prevalence ratio (APR) controlling for sociodemographic, health and other disability factors. RESULTS: Among community dwelling older adults, having CDs was associated with higher utilization of a communication support person at medical visits (APR: 1.41 [CI: 1.27 - 1.57]). Among adults with CDs, Black adults and women had lower levels of utilization as compared to White adults and men, respectively. CONCLUSION: Communication support persons may be a way that older adults with CDs self-support their disability. However, not all older adults with CDs bring someone and variation by social factors could suggest that unmet support needs exist.

Over half of older adults with communication disabilities do not utilize a communication support person at doctors' visits, and utilization differs by race and gender.Rehabilitation professionals should educate their older adult patients with communication disabilities on this practice and collaborate with speech-language pathologists (SLPs) and audiologists (AuDs) on how to accommodate this population's disability.SLPs and AuDs can directly train support persons, other rehabilitation professionals, and physicians on accommodating these patients. For patients who don't bring a support person, SLPs and AuDs can plan alternative communication disability supports to use in healthcare settings, so that all older adults with CDs can equitably access their healthcare.

How Health Care Organizations Are Implementing Disability Accommodations for Effective Communication: A Qualitative Study.

BACKGROUND: Prior studies have documented that, despite federal mandates, clinicians infrequently provide accommodations that enable equitable health care engagement for patients with communication disabilities. To date, there has been a paucity of empirical research describing the organizational approach to implementing these accommodations. The authors asked US health care organizations how they were delivering these accommodations in the context of clinical care, what communication accommodations they provided, and what disability populations they addressed. METHODS: In this study, 19 qualitative interviews were conducted with disability coordinators representing 15 US health care organizations actively implementing communication accommodations. A conventional qualitative content analysis approach was used to code the data and derive themes. RESULTS: The authors identified three major themes related to how US health care organizations are implementing the provision of this service: (1) Operationalizing the delivery of communication accommodations in health care required executive leadership support and preparatory work at clinic and organization levels; (2) The primary focus of communication accommodations was sign language interpreter services for Deaf patients and, secondarily, other hearing- and visual-related accommodations; and (3) Providing communication accommodations for patients with speech and language and cognitive disabilities was less frequent, but when done involved more than providing a single aid or service. CONCLUSION: These findings suggest that, in addition to individual clinician efforts, there are organization-level factors that affect consistent provision of communication accommodations across the full range of communication disabilities. Future research should investigate these factors and test targeted implementation strategies to promote equitable access to health care for all patients with communication disabilities.

Prevalence and sociodemographic characteristics of US community-dwelling older adults with communication disabilities, using the national health and aging trends survey.

INTRODUCTION: Identifying the population-level prevalence of a disability group is a prerequisite to monitoring their inclusion in society. The prevalence and sociodemographic characteristics of older adults with communication disabilities (CDs) are not well established in the literature. In this study we sought to describe the prevalence and sociodemographic characteristics of community-dwelling older adults experiencing difficulties with understanding others or being understand when communicating in their usual language. METHODS: We conducted a cross-sectional analysis of the National Health and Aging Trends Survey (2015), a nationally representative survey of Medicare beneficiaries ages ≥ 65 years old (N = 7,029). We calculated survey weight-adjusted prevalence estimates by mutually exclusive subgroups of no, hearing only, expressive-only, cognitive only, multiple CDs, and an aggregate any-CD prevalence. We described race/ethnicity, age, gender, education, marital status, social network size, federal poverty status, and supplemental insurance for all groups. Pearson's chi-squared statistic was used to compare sociodemographic characteristics between the any-CD and no-CD groups. RESULTS: An estimated 25.3% (10.7 million) of community-dwelling older adults in the US experienced any-CDs in 2015; approximately 19.9% (8.4 million) experienced only one CD while 5.6% (2.4 million) had multiple. Older adults with CDs were more likely to be of Black race or Hispanic ethnicity as compared to older adults without CDs (Black 10.1 vs. 7.6%; Hispanic: 12.5 vs. 5.4%; P < 0.001). They also had lower educational attainment (Less than high school: 31.0 vs 12.4%; P < 0.001), lower poverty levels (<100% Federal poverty level: 23.5% vs. 11.1%; P < 0.001) and less social supports (Married: 51.3 vs. 61.0%; P < 0.001; Social network ≤ 1 person: 45.3 vs 36.0%; P < 0.001). CONCLUSIONS: The proportion of the older adult population experiencing any-CDs is large and disproportionately represented by underserved sociodemographic groups. These findings support greater inclusion of any-CDs into population-level efforts like national surveys, public health goals, health services, and community research aimed at understanding and addressing the access needs of older adults who have disabilities in communication.

Association between the prevalence of obstructive lung disease and the use of aspirin in a diabetic population.

Background: Many diabetic patients take a daily low-dose of aspirin because they are two to three times more likely to suffer from heart attacks and strokes, but its role in obstructive lung diseases is less clear. Methods: A total of 1,003 subjects in community practice settings were interviewed at home. Patients self-reported their personal and clinical characteristics, including any history of obstructive lung disease (including COPD or asthma). Current medications were obtained by the direct observation of medication containers. We performed a cross-sectional analysis of the interviewed subjects to assess for a possible association between obstructive lung disease history and the use of aspirin. Results: In a multivariate logistic regression model, a history of obstructive lung disease was significantly associated with the use of aspirin even after correcting for potential confounders, including gender, low income (

Association between prevalence of obstructive lung disease and obesity: results from The Vermont Diabetes Information System.

BACKGROUND: The association of obesity with the development of obstructive lung disease, namely asthma and/or chronic obstructive pulmonary disease, has been found to be significant in general population studies, and weight loss in the obese has proven beneficial in disease control. Obese patients seem to present with a specific obstructive lung disease phenotype including a reduced response to corticosteroids. Obesity is increasingly recognized as an important factor to document in obstructive lung disease patients and a critical comorbidity to report in diabetic patients, as it may influence disease management. This report presents data that contributes to establishing the relationship between obstructive lung disease in a diabetic cohort, a population highly susceptible to obesity. METHODS: A total of 1003 subjects in community practice settings were interviewed at home at the time of enrolment into the Vermont Diabetes Information System, a clinical decision support program. Patients self-reported their personal and clinical characteristics, including any history of obstructive lung disease. Laboratory data were obtained directly from the clinical laboratory, and current medications were obtained by direct observation of medication containers. We performed a cross-sectional analysis of the interviewed subjects to assess a possible association between obstructive lung disease history and obesity. RESULTS: In a multivariate logistic regression model, a history of obstructive lung disease was significantly associated with obesity (body mass index ≥30) even after correcting for potential confounders including gender, low income (<$30,000/year), number of comorbidities, number of prescription medications, cigarette smoking, and alcohol problems (adjusted odds ratio (OR) = 1.58, P = 0.03, 95% confidence interval (CI) = 1.05, 2.37). This association was particularly strong and significant among female patients (OR = 2.18, P = < 0.01, CI = 1.27, 3.72) but not in male patients (OR = 0.97, P = 0.93, CI = 0.51, 1.83). CONCLUSION: These data suggest an association between obesity and obstructive lung disease prevalence in patients with diabetes, with women exhibiting a stronger association. Future studies are needed to identify the mechanism by which women disproportionately develop obstructive lung disease in this population.

Jobs, Housing, and Mask Wearing: Cross-Sectional Study of Risk Factors for COVID-19.

BACKGROUND: Many studies have focused on the characteristics of symptomatic patients with COVID-19 and clinical risk factors. This study reports the prevalence of COVID-19 in an asymptomatic population of a hospital service area (HSA) and identifies factors that affect exposure to the virus. OBJECTIVE: The aim of this study is to measure the prevalence of COVID-19 in an HSA, identify factors that may increase or decrease the risk of infection, and analyze factors that increase the number of daily contacts. METHODS: This study surveyed 1694 patients between April 30 and May 13, 2020, about their work and living situations, income, behavior, sociodemographic characteristics, and prepandemic health characteristics. This data was linked to testing data for 454 of these patients, including polymerase chain reaction test results and two different serologic assays. Positivity rate was used to calculate approximate prevalence, hospitalization rate, and infection fatality rate (IFR). Survey data was used to analyze risk factors, including the number of contacts reported by study participants. The data was also used to identify factors increasing the number of daily contacts, such as mask wearing and living environment. RESULTS: We found a positivity rate of 2.2%, a hospitalization rate of 1.2%, and an adjusted IFR of 0.55%. A higher number of daily contacts with adults and older adults increases the probability of becoming infected. Occupation, living in an apartment versus a house, and wearing a face mask outside work increased the number of daily contacts. CONCLUSIONS: Studying prevalence in an asymptomatic population revealed estimates of unreported COVID-19 cases. Occupational, living situation, and behavioral data about COVID-19-protective behaviors such as wearing a mask may aid in the identification of nonclinical factors affecting the number of daily contacts, which may increase SARS-CoV-2 exposure.

Potential enhanced association between obstructive lung disease and history of depression in patients with diabetes.

BACKGROUND: Depression is one of the most common comorbidities of chronic diseases including diabetes and obstructive lung diseases (emphysema, chronic bronchitis, and asthma). Obstructive lung diseases and depression have few symptoms in common. However, they are both common in adults and associated with chronic inflammation. It is not clear if their coappearance in diabetic patients is coincidental or associated beyond that expected by chance. METHODS: A total of 1,003 adults with diabetes in community practice settings were interviewed at home at the time of their enrolment into the Vermont Diabetes Information System, a clinical decision support program. Patients self-reported their personal and clinical characteristics, including any obstructive lung disease. Laboratory data were obtained directly from the clinical laboratory, and current medications were obtained by direct observation of medication containers. We performed a cross-sectional analysis of the interviewed subjects to assess a possible association between the prevalence of obstructive lung disease and depression. RESULTS: In a multivariate logistic regression model, obstructive lung disease was significantly associated with depression even after correcting for gender, obesity (≥30 kg/m2), high comorbidities (>2), low annual income (<$30,000/ year), cigarette smoking, alcohol problems, and education level (odds ratio=1.83; 95% confidence interval 1.27, 2.62; P <0.01). CONCLUSION: These data suggest a potential enhanced association between obstructive lung disease and depression in patients with diabetes. Future studies are needed to identify if inflammation is implicated in this association as a common denominator.

Use and Reported Helpfulness of Cannabinoids Among Primary Care Patients in Vermont.

Introduction: While cannabis has been medically legal in Vermont since 2004 and recreationally legal since 2018 there has been minimal published research regarding the use and practices in the adult population. This gap in understanding results in primary care providers having difficulty navigating conversations surrounding cannabinoid use. The purpose of this research was to identify current use and perceptions of cannabinoids, including Δ9-tetrahydrocannabinol (THC) and cannabidiol (CBD), in adult primary care patients in Vermont. Methods: An anonymous written survey was given to 1009 Vermont primary care patients aged 18 years and older. All measures were patient-reported and included use of CBD and THC products, perceived helpfulness for certain medical conditions, knowledge of CBD and THC, perceived knowledge of their provider, and concerns regarding cannabis legalization. Results: 45% of adult primary care patients reported using cannabinoids in the past year. Only 18% of patients reported their provider as being a good source of information regarding cannabis. Of the patients who used cannabis in the past year, a majority reported it helpful for conditions such as anxiety and depression, arthritis, pain, sleep, and nausea. Conclusions: Primary care providers need to be knowledgeable about cannabinoids to best support patient care. In addition, with a significant number of patients reporting cannabinoids helpful for medical conditions common in primary care, it is important that research continue to identify the potential benefits and harms of cannabis.

Patients' Experience With Opioid Pain Medication After Discharge From Surgery: A Mixed-Methods Study.

BACKGROUND: Decreasing the number of prescription opioids has been a leading strategy in combating the opioid epidemic. In Vermont, statewide and institutional policies have affected prescribing practices, resulting in a 40% decrease in postoperative opioid prescribing. The optimal approach to postoperative opioid prescribing remains unknown. In this study, we describe patients' experience with pain control 1 wk after discharge from surgery. MATERIALS AND METHODS: We assessed patients' experience using a telephone questionnaire, 1-wk after discharge after undergoing common surgical procedures between 2017 and 2019 at an academic medical center (n = 1027). Scaled responses regarding pain control, opioids prescribed, and opioids used (response rate 96%) were analyzed using a mixed-methods approach; open-ended patient responses to questions regarding whether the number of opioids prescribed was "correct" were analyzed using qualitative content analysis. RESULTS: One week after discharge, 96% of patients reported that their pain was well controlled. When asked whether they received the correct number of opioid pills postoperatively, qualitative analysis of patient responses yielded the following six themes: (1) I had more than I needed, but not more than I wanted; (2) Rationed medication; (3) Medication was not effective; (4) Caution regarding risks of opioids; (5) Awareness of the public health concerns; and (6) Used opioids from a prior prescription. CONCLUSIONS: Patient-reported pain control after common surgical procedures was excellent. However, patients are supportive of receiving more pain medications than they actually use, and they fear that further restrictions may prevent them or others from managing pain adequately. Understanding the patients' perspective is important for surgical education and improving discharge protocols.

A New Quality Improvement Toolkit to Improve Opioid Prescribing in Primary Care.

INTRODUCTION: The role of opioids in managing chronic pain has evolved in light of the opioid misuse epidemic and new evidence regarding risks and benefits of long-term opioid therapy. With mounting national guidelines and local regulations, providers need interventions to standardize and improve safe, responsible prescribing. This article summarizes the evolution of an opioid management toolkit using a quality improvement (QI) approach to improve prescribing. METHODS: The authors developed a list of opioid-prescribing best practices and offered in-office, team-based QI projects to ambulatory clinics, updated and tested over 3 trials in the form of a toolkit. Outcome measures included pre- and postproject surveys on provider and staff satisfaction, toolkit completion, and process measures. The toolkit supports workflow planning, redesign, and implementation. RESULTS: Ten clinics participated in trial 1, completing the QI project on average in 3 months, with a mean of 9.1 hours of team time. Provider satisfaction with prescribing increased from 42% to 96% and staff satisfaction from 54% to 81%. The most common strategies in trials 1 and 2 focused on regulatory compliance (35% to 36%), whereas in Trial 3 there was a strong move toward peer support (81%). DISCUSSION: Clinics responded to implementation of opioid-related best practices using QI with improved provider and staff satisfaction. Once the goals of regulatory compliance and workflow improvements were met, clinics focused on strategies supporting providers in the lead role of managing chronic pain, building on strategies that provide peer support. Using QI methods, primary care clinics can improve opioid-prescribing best practices for patients.

Order From Chaos: An Initiative to Improve Opioid Prescribing in Rheumatology Using Lean A3.

OBJECTIVE: Use an established quality improvement method, Lean A3, to improve the process of opioid prescribing in an academic rheumatology ambulatory clinic. METHODS: This retrospective pre-postintervention analysis of rheumatology records included patients prescribed opioids at least once during the study period. Lean A3 was used to develop a Controlled Substance Visit Protocol to standardize eight recommended elements of the opioid prescribing workflow. Analyses included changes in the recommended workflow elements and changes in opioid prescribing volume. RESULTS: Improvements were observed in seven of the eight recommended elements. Patient education, including treatment agreements and consent forms (39% completion for both preimplementation) increased to 78% and 80%, respectively (P < 0.001 for both). Risk assessment, as measured by the Current Opioid Misuse Measure, increased from 0.5% to 76% (P < 0.001). Best practices in prescribing, including prescribing in multiples of seven to avoid weekend refill requests, increased from 1% to 79% (P < 0.001). Monitoring parameters, including standardized functional assessment (0% vs. 86%), prescription drug monitoring program queries (49% vs. 84%), and urine testing (1% vs. 32%) all increased (P < 0.001). Visits scheduled at least quarterly for patients on chronic opioids did not change (P = 0.18). Overall, the number of patients prescribed opioids (185 vs. 160; P < 0.001) and annual prescription opioid morphine milligram equivalents (MMEs) (1 933 585 MME vs. 1 386 368 MME; P < 0.001) decreased. CONCLUSION: The Lean A3 method is a successful quality improvement tool for improving and sustaining opioid prescribing within a single academic rheumatology clinic. This method has potential applicability to similar clinics interested in improving opioid prescribing.

Risk factors for cancer-associated venous thromboembolism: The venous thromboembolism prevention in the ambulatory cancer clinic (VTE-PACC) study.

BACKGROUND: The Khorana Score is a validated risk score for predicting 6-month incidence of cancer-associated venous thromboembolism (CAT) among patients starting chemotherapy. Venous thromboembolism (VTE) risk factors important in the general population, including age, sex, prior VTE, and hospitalization, are not included in this score, their association with VTE in cancer patients is unknown. OBJECTIVE: To examine risk factors for CAT and the impact of incorporating longitudinal hospitalization into risk assessment. METHODS: Risk factors were recorded among patients starting chemotherapy at a single institution from 2012-14. Hospitalization and time-periods after hospitalization were assessed as time-varying covariates. Logistic regression was used to determine factors related to 6-month CAT risk (the Khorana Score endpoint). Proportional hazard models were used for risk factor identification throughout the 3-year observation period. RESULTS: Among 1,583 patients starting chemotherapy (mean age 60, 48% male), 187 developed CAT (11.8%) with 129 (69%) cases occurring within 6 months of starting chemotherapy. In the 6-month analysis, no additional risk factors were associated with CAT. In the 3-year analysis, male sex (HR 1.57, 95%CI 1.21, 2.07), prior VTE (HR 2.12, 95%CI 1.41, 3.18), and hospitalization (HR 2.69, 95%CI 1.92, 3.75) were associated with increased hazard of CAT, adjusting for risk factors in the Khorana score. CONCLUSIONS: When time-to-event data were incorporated into CAT risk assessment, male sex, prior VTE, and hospitalization were important risk factors. These data highlight the need to consider dynamic methods for assessing VTE risk in cancer patients, with particular attention to the period around hospitalizations.

Impact of Policy Interventions on Postoperative Opioid Prescribing.

OBJECTIVE: To assess postoperative opioid prescribing in response to state and organizational policy changes. METHODS: We used an observational study design at an academic medical center in the Northeast United States over a time during which there were two important influences: 1) implementation of state rules regarding opioid prescribing and 2) changes in organization policies reflecting evolving standards of care. Results were summarized at the surgical specialty and procedure level and compared between baseline (July-December 2016) and postrule (July-December 2017) periods. RESULTS: We analyzed data from 17,937 procedures from July 2016 to December 2017, two-thirds of which were outpatient. Schedule II opioids were prescribed in 61% of cases and no opioids at all in 28%. The median morphine milligram equivalent (MME) prescribed at discharge decreased 40%, from 113 MME in the baseline period to 68 MME in the postrule period. Decreases were seen across all the surgical specialties. CONCLUSIONS: Postoperative opioid prescribing at the time of hospital discharge decreased between 2016 and 2017 in the setting of targeted and replicable state and health care organizational policies. POLICY IMPLICATIONS: Policies governing the use of opioids are an effective and adoptable approach to reducing opioid prescribing following surgery.

Postoperative opioid prescribing patterns and use after vascular surgery.

The aim of this study was to assess postoperative opioid prescribing patterns, usage, and pain control after common vascular surgery procedures in order to develop patient centered best-practice guidelines. We performed a prospective review of opioid prescribing after seven common vascular surgeries at a rural, academic medical center from December 2016 to July 2017. A standardized telephone questionnaire was prospectively administered to patients ( n = 110) about opioid use and pain management perceptions. For comparison we retrospectively assessed opioid prescribing patterns ( n = 939) from July 2014 to June 2016 normalized into morphine milligram equivalents (MME). Prescribers were surveyed regarding opioid prescription attitudes, perceptions, and practices. Opioids were prescribed for 78% of procedures, and 70% of patients reported using opioid analgesia. In the prospective group, the median MMEs prescribed were: VEIN (31, n = 16), CEA (40, n = 14), DIAL (60, n = 17), EVAR (108, n = 8), INFRA (160, n = 16), FEM TEA (200, n = 11), and OA (273, n = 4). The median proportion of opioids used by patients across all procedures was only 30% of the amount prescribed across all procedures (range 14-64%). Patients rated the opioid prescribed as appropriate (59%), insufficient (16%), and overprescribed (25%), and pain as very well controlled (47%), well controlled (47%), poorly controlled (4%), and very poorly controlled (2%). In conclusion, we observed significant variability in opioid prescribing after vascular procedures. The overall opioid use was substantially lower than the amount prescribed. These data enabled us to develop guidelines for opioid prescribing practice for our patients.

Internal Medicine Resident Experiences With a 5-Month Ambulatory Panel Management Curriculum.

BACKGROUND: Panel management is emphasized as a subcompetency in internal medicine graduate medical education. Despite its importance, there are few published curricula on population medicine in internal medicine residency programs. OBJECTIVE: We explored resident experiences and clinical outcomes of a 5-month diabetes and obesity ambulatory panel management curriculum. METHODS: From August through December 2016, internal medicine residents at the University of Vermont Medical Center reviewed registries of their patients with diabetes, prediabetes, and obesity; completed learning modules; coordinated patient outreach; and updated gaps in care. Resident worksheets, surveys, and reflections were analyzed using descriptive and thematic analyses. Before and after mean hemoglobin A1c results were obtained for patients in the diabetic group. RESULTS: Most residents completed the worksheet, survey, and reflection (93%-98%, N = 42). The worksheets showed 70% of participants in the diabetic group had appointments scheduled after outreach, 42% were offered referrals to the Community Health Team, and 69% had overdue laboratory tests ordered. Residents reported they worked well with staff (95%), were successful in coordinating outreach (67%), and increased their sense of patient care ownership (66%). In reflections, identified successes were improved patient care, teamwork, and relationship with patients, while barriers included difficulty ensuring follow-up, competing patient priorities, and difficulty with patient engagement. Precurricular mean hemoglobin A1c was 7.7%, and postcurricular was 7.6% (P = .41). CONCLUSIONS: The curriculum offered a feasible, longitudinal model to introduce residents to population health skills and interdisciplinary care coordination. Although mean hemoglobin A1c did not change, residents reported improved patient care. Identified barriers present opportunities for resident education in patient engagement.

Utilization Outcomes of a Pilot Primary Care Team Redesign.

OBJECTIVES: To evaluate the effect of a team-based primary care redesign on primary care, emergency department (ED) and urgent care (UC) utilization, and new patient access to primary care. STUDY DESIGN: A retrospective pre-post difference-in-differences analysis of utilization outcomes for patients on a redesigned primary care team compared to a standard primary care group. METHODS: Within a patient-centered medical home, a pilot team was developed comprising 2 colocated "teamlets" of 1 physician, 1 nurse practitioner (NP), 1 registered nurse (RN), and 2 licensed practical nurses (LPNs). The redesigned team utilized physician-NP comanagement, expanded roles for RNs and LPNs, and dedicated provider time for telephone and e-mail medicine. We compared changes in number of office, ED, and UC visits during the implementation year for patients on the redesigned team compared to patients receiving the standard of care in the same clinic. Proportion of new patient visits was also compared between the pilot and the control groups. RESULTS: There were no differences between the redesign group and control group in per-patient mean change in office visits (Δ = -0.04 visits vs Δ = -0.07; P = .98), ED visits (Δ = 0.00 vs Δ = 0.01; P = .25), or UC visits (Δ = 0.00 vs Δ = 0.05; P = .08). Proportion of new patient visits was higher in the pilot group during the intervention year compared to the control group (6.6% vs 3.9%; P < .0001). CONCLUSIONS: The redesign did not significantly impact ED, UC, or primary care utilization within 1 year of follow-up. It did improve access for new patients.

Post-Discharge Opioid Prescribing and Use after Common Surgical Procedure.

BACKGROUND: The number of deaths from prescription opioids in the US continues to increase and remains a major public health concern. Opioid-related deaths parallel prescribing trends, and postoperative opioids are a significant source of opioids in the community. Our objective was to identify opioid prescribing and use patterns after surgery to inform evidence-based practices. STUDY DESIGN: Data from a 340-bed academic medical institution and its affiliated outpatient surgical facility included retrospective medical record data and prospective telephone questionnaire and medical record data. Retrospective data included patients discharged after 1 of 19 procedure types, from July 2015 to June 2016 (n = 10,112). Prospective data included a consecutive sample of general and orthopaedic surgery and urology patients undergoing 1 of 13 procedures, from July 2016 to February 2017 (n = 539). Primary outcomes were the quantity of opioid prescribed and used in morphine milligram equivalents (MME), and the proportion of patients receiving instructions on disposal and nonopioid strategies. RESULTS: In the retrospective dataset, 76% of patients received an opioid after surgery, and 87% of prescriptions were prescribed by residents or advanced practice providers. Median prescription size ranged from 0 to 503 MME, with wide interquartile ranges (IQR) for most procedures. In the prospective dataset, there were 359 participants (67% participation rate). Of these, 92% of patients received an opioid and the median proportion used was 27%, or 24 MME (IQR 0 to 96). Only 18% of patients received disposal instructions, while 84% of all patients received instructions on nonopioid strategies. CONCLUSIONS: Median opioid use after surgery was 27% of the total prescribed, and only 18% of patients reported receiving disposal instructions. Significant variability in opioid prescribing and use after surgery warrants investigation into contributing factors.

Basic and Advanced EMS Providers Are Equally Effective in Naloxone Administration for Opioid Overdose in Northern New England.

OBJECTIVE: Overdose mortality from illicit and prescription opioids has reached epidemic proportions in the United States, especially in rural areas. Naloxone is a safe and effective agent that has been shown to successfully reverse the effects of opioid overdose in the prehospital setting. The National EMS Scope of Practice Model currently only recommends advanced life support (ALS) providers to administer naloxone; however, some individual states have expanded this scope of practice to include intranasal (IN) administration of naloxone by basic life support (BLS) providers, including the Northern New England states. This study compares the effectiveness and appropriateness of naloxone administration between BLS and ALS providers. METHODS: All Vermont, New Hampshire, and Maine EMS patient encounters between April 1, 2014 and December 31, 2016 where naloxone was administered were examined and 3,219 patients were identified. The proportion of successful reversals of opioid overdose, based on improvement in the Glasgow Coma Scale (GCS), respiratory rate (RR), and provider global assessment (GA) of response to medication was compared between BLS and ALS providers using a Chi-Squared statistic, Fisher's exact or Wilcoxon rank-sum test. RESULTS: There was no significant difference in the percent improvement in GCS between BLS and ALS (64% and 64% P = 0.94). There was no significant difference in the percentage of improvement in RR between BLS and ALS (45% and 48% P = 0.43). There was a significant difference in the percentage of improvement of GA between BLS and ALS (80% and 67% P < 0.001). There was no significant difference in determining appropriate cases to administer naloxone where RR < 12 and GCS < 15 between BLS and ALS (42% and 43% P = 0.94). CONCLUSIONS: BLS providers were as effective as ALS providers in improving patient outcome measures after naloxone administration and in identifying patients for whom administration of naloxone is appropriate. These findings support expanding the National EMS Scope of Practice Model to include BLS administration of intranasal naloxone for suspected opioid overdoses.

Implementation of the universal BLS termination of resuscitation rule in a rural EMS system.

BACKGROUND: Emergency Medical Services (EMS) are often the first medical providers to begin resuscitation of out-of-hospital cardiac arrest (OHCA) victims. The universal Basic Life Support Termination of Resuscitation (BLS-TOR) rule is a validated clinical prediction tool used to identify patients in which continued resuscitation efforts are futile. OBJECTIVE: The primary aim is to compare the rate of transport of OHCA cases before and after the implementation of a BLS-TOR protocol and to determine the compliance rate of EMS personnel with the new protocol in a largely volunteer, rural system. METHODS: A retrospective cohort study was conducted using the statewide EMS electronic patient care report system. Cases were identified by searching for any incident that had a primary impression of "cardiac arrest" or a primary symptom of "cardiorespiratory arrest" or "death." Data were collected from the two years prior to and following implementation of the BLS-TOR rule from January 1, 2012 through March 31, 2016. RESULTS: There were 702 OHCA cases were identified, with 329 cases meeting inclusion criteria. The transport rate was 91.1% in the pre-intervention group compared with 69.4% in the post-intervention group (χ2=24.8; p<0.001). EMS compliance rate with the BLS-TOR rule was 66.7%. Of the 265 patients transported during the study, 87 patients met (post-intervention group; n=22) or retrospectively met (pre-intervention group; n=65) the BLS-TOR requirements for field termination of resuscitation. None of these patients survived to hospital discharge. CONCLUSION: Rural EMS systems may benefit from implementation and utilization of the universal BLS-TOR rule.

Role of magnesium supplementation in the treatment of depression: A randomized clinical trial.

Current treatment options for depression are limited by efficacy, cost, availability, side effects, and acceptability to patients. Several studies have looked at the association between magnesium and depression, yet its role in symptom management is unclear. The objective of this trial was to test whether supplementation with over-the-counter magnesium chloride improves symptoms of depression. An open-label, blocked, randomized, cross-over trial was carried out in outpatient primary care clinics on 126 adults (mean age 52; 38% male) diagnosed with and currently experiencing mild-to-moderate symptoms with Patient Health Questionnaire-9 (PHQ-9) scores of 5-19. The intervention was 6 weeks of active treatment (248 mg of elemental magnesium per day) compared to 6 weeks of control (no treatment). Assessments of depression symptoms were completed at bi-weekly phone calls. The primary outcome was the net difference in the change in depression symptoms from baseline to the end of each treatment period. Secondary outcomes included changes in anxiety symptoms as well as adherence to the supplement regimen, appearance of adverse effects, and intention to use magnesium supplements in the future. Between June 2015 and May 2016, 112 participants provided analyzable data. Consumption of magnesium chloride for 6 weeks resulted in a clinically significant net improvement in PHQ-9 scores of -6.0 points (CI -7.9, -4.2; P<0.001) and net improvement in Generalized Anxiety Disorders-7 scores of -4.5 points (CI -6.6, -2.4; P<0.001). Average adherence was 83% by pill count. The supplements were well tolerated and 61% of participants reported they would use magnesium in the future. Similar effects were observed regardless of age, gender, baseline severity of depression, baseline magnesium level, or use of antidepressant treatments. Effects were observed within two weeks. Magnesium is effective for mild-to-moderate depression in adults. It works quickly and is well tolerated without the need for close monitoring for toxicity.