Reported Political Participation by Physicians vs Nonphysicians.

This study uses survey data to compare rates of political participation between US physicians and nonphysicians from 2017 to 2021.

A National Voter Registration Campaign.

Research suggests that increased voting among adults is associated with improved child health. Despite the benefits of voting, the United States has low voter turnout compared with peer nations. Turnout is especially low among marginalized people in the United States. Voter registration is essential for increasing voter turnout, and registration efforts have been successfully carried out in clinical settings. Working with a nonprofit called Vot-ER, we advocated for nonpartisan voter registration efforts in pediatric settings nationwide preceding the November 2020 US elections. We describe lessons learned from these efforts. Using data obtained from Vot-ER, we also provide the first estimates of participation in a national voter registration campaign in pediatric settings. There was widespread engagement in voter registration efforts among pediatricians in 2020. Many lessons were learned from these efforts, including the benefits of advanced planning because registration deadlines can be up to 1 month in advance of Election Day. Obtaining buy-in from numerous stakeholders (e.g., health center leadership, public relations teams) supports widespread staff participation. Also important is to consider the tradeoffs between active voter registration (in which staff can broach the topic of voting with patients and families) and passive efforts (in which voting is discussed only if patients or families inquire about it). These and other lessons can inform future voter registration efforts in diverse pediatric settings across the country.

The Healthy Democracy Kit: design, implementation, uptake, and impact of a novel voter registration toolkit for healthcare settings.

BACKGROUND: Access to voting is increasingly recognized as a social determinant of health. Health equity could be improved if healthcare workers (HCWs) routinely assessed the voter registration status of patients during clinical encounters and helped direct them towards appropriate resources. However, little consensus exists on how to achieve these tasks efficiently and effectively in healthcare settings. Intuitive and scalable tools that minimize workflow disruptions are needed. The Healthy Democracy Kit (HDK) is a novel voter registration toolkit for healthcare settings, featuring a wearable badge and posters that display quick response (QR) and text codes directing patients to an online hub for voter registration and mail-in ballot requests. The objective of this study was to assess national uptake and impact of the HDK prior to the 2020 United States (US) elections. METHODS: Between 19 May and 3 November 2020, HCWs and institutions could order and use HDKs to help direct patients to resources, free of cost. A descriptive analysis was conducted to summarize the characteristics of participating HCWs and institutions as well as the resultant total persons helped prepare to vote. RESULTS: During the study period, 13,192 HCWs (including 7,554 physicians, 2,209 medical students, and 983 nurses) from 2,407 affiliated institutions across the US ordered 24,031 individual HDKs. Representatives from 604 institutions (including 269 academic medical centers, 111 medical schools, and 141 Federally Qualified Health Centers) ordered 960 institutional HDKs. Collectively, HCWs and institutions from all 50 US states and the District of Columbia used HDKs to help initiate 27,317 voter registrations and 17,216 mail-in ballot requests. CONCLUSIONS: A novel voter registration toolkit had widespread organic uptake and enabled HCWs and institutions to successfully conduct point-of-care civic health advocacy during clinical encounters. This methodology holds promise for future implementation of other types of public health initiatives. Further study is needed to assess downstream voting behaviors from healthcare-based voter registration.

Analyzing opioid-use disorder websites in the United States: An optimized website usability study.

Background: As the United States continues to tackle the opioid epidemic, it is imperative for digital healthcare organizations to provide Internet users with accurate and accessible online resources so that they can make informed decisions with regards to their health. Objective: The primary objectives were to adapt and modify a previously established usability methodology from literature, apply this modified methodology in order to perform usability analysis of opioid-use-disorder (OUD)-related websites, and make important recommendations that OUD-related digital health organizations may utilize to improve their online presence. Methods: A list of 208 websites (later refined) was generated for usability testing using a modified Google Search methodology. Four keywords were chosen and used in the search: "DEA-X Waiver Training", "opioid-use-disorder (OUD) Initiatives", "Buprenorphine Assisted Treatment", and "Opioid-Use Disorder Websites". Usability analysis was performed concurrently with optimization of the methodology. OUD websites were analyzed and scored on several usability categories established by previous literature. Results: "DEA-X Waiver Training" yielded websites that scored the highest average in "Accessibility" (0.84), while "Opioid-Use Disorder Websites" yielded websites that scored the highest average in "Content Quality" (0.67). "Buprenorphine Assisted Treatment" yielded websites that scored the highest average across "Marketing" (0.52), "Technology" (0.89), "General Usability" (0.69), and "Overall Usability" (0.68). "Technology" and "Marketing" were the highest and lowest scoring usability categories, respectively. T-test analysis revealed that each usability, except "Marketing" had a pair of one or more keywords that were significantly different with a p-value that was equal to or less than 0.05. Conclusions: Based on the study findings, we recommend that digital organizations in the OUD space should improve their "General Usability" score by making their websites easier to find online. Doing so, may allow users, especially individuals in the OUD space, to discover accurate information that they are seeking. Based on the study findings, we also made important recommendations that OUD-related digital organizations may utilize in order to improve website usability as well as overall reach.

Why and How Civic Health Should Be Incorporated Into Medical Education.

Civic health refers to the ability of a community to organize and collectively address problems that affect the well-being of its members through democratic participation. Civic health should be an integral part of the medical school curriculum because improving a community's civic health shifts the distribution of power toward patients, better enabling them to address social determinants of health that are affecting their well-being. This article details how to effectively integrate civic health curriculum into already-existing medical education frameworks, outlines how these interventions will improve both patient care and the student experience, and addresses barriers that might restrict the implementation. Civic health can be integrated into the didactic curriculum in the form of lunchtime guest lectures, panels with community organizations, and small-group discussions; it can be integrated into experiential curriculum by distributing QR codes to aid in voter registration, organizing voter registration drives, and participating in nonpartisan canvassing. This civic health content can be integrated into existing social justice curricula without massive investment or structural change. Medical students are capable and effective messengers of civic health and can affect change at all levels of training. Notably, because civic health is directly actionable, it can be a source of motivation rather than burnout for medical students. As students develop into medical professionals, the training in civic health improves their understanding of social determinants of health and enables them to play an important role in promoting civic engagement and empowering patients with the democratic tools necessary to enact social change.

Health system-based housing navigation for patients experiencing homelessness: A new care coordination framework.

Patients experiencing homelessness are among the most disadvantaged in our society, suffering from poor health outcomes and exhibiting disproportionately high hospital utilization and spending. However, to date, hospitals have only scantily devoted time or resources to the housing coordination aspect of homelessness. Implementing better systems to coordinate housing for patients experiencing homelessness may improve health outcomes and reduce health care utilization for this population. This objective is now more important than ever as the economic impact of COVID-19 is expected to exacerbate the homelessness crisis. Ensuring that patients are properly connected to temporary or permanent housing is valuable to patient health, health care system metrics such as excess spending and utilization, and provider performance under Accountable Care Organizations or other risk-bearing payment models. Here, we propose a health systems-based housing coordination framework that may improve care delivery for patients experiencing homelessness. This framework relies on the coordination between dedicated hospital-based housing navigators who can identity patients experiencing homelessness and outpatient housing navigators equipped to coordinate short- and long-term housing specifically for patients experiencing homelessness who frequently interact with the health care system.

Continuation of outpatient buprenorphine therapy after dispensing Buprenorphine-Naloxone from the emergency department.

BACKGROUND: Patients with opioid use disorder (OUD) are frequently seen in the ED for opioid-related reasons, which creates an opportunity for ED providers to discuss medications for OUD with their patients. Buprenorphine is a partial mu-opioid agonist that is FDA approved to treat OUD and may be initiated in the ED. Traditionally, buprenorphine therapy was initiated under healthcare provider observation; however, other strategies such as at-home induction have also emerged. METHODS: This was a retrospective descriptive analysis of patients aged 18 years or older who received a take-home supply of buprenorphine-naloxone from an urban, academic ED between March 2018 and March 2020. The primary outcome was the proportion of patients who filled a prescription for buprenorphine at three months after index ED visit. The proportion of patients that filled a prescription for buprenorphine at six months was also evaluated. The primary safety endpoint was the proportion of patients with return ED visit within six months related to opioid overdose. RESULTS: There were 242 patient records reviewed with 155 patients included in final analysis. Seventy (45.2%) patients filled buprenorphine prescriptions at three months, with 64 (41.3%) who filled buprenorphine prescriptions at six months. Seventeen (11%) patients had a return ED visit related to opioid overdose within six months. CONCLUSION: Dispensing buprenorphine take-home kits from the ED resulted in continuation of outpatient buprenorphine in almost 50% of patients. Further studies are warranted to define the role of ED-dispensed buprenorphine.

Emergency Department-initiated Buprenorphine and Referral to Follow-up Addiction Care: A Program Description.

INTRODUCTION: Emergency department (ED) initiated opioid use disorder (OUD) care is effective; however, real-world predictors of patient engagement are lacking. OBJECTIVE: This program evaluation examined predictors of ED-based OUD treatment and subsequent engagement. METHOD: Program evaluation in Boston, MA. Adult patients who met criteria for OUD during an ED visit in 2019 were included. Patients were included if a diagnosis of OUD or opioid-related overdose was associated with the ED visit or if they met previously validated criteria for OUD within the previous 12 months. We assessed predictors of ED-OUD treatment receipt and subsequent engagement, using Healthcare Effectiveness Data and Information Set definition of initial encounter within 14 days of discharge and either 2 subsequent encounters or a subsequent buprenorphine prescription within 34 days of the initial encounter. We used generalized estimating equations for panel data. RESULTS: During 2019, 1946 patients met criteria for OUD. Referrals to Bridge Clinic were made for 207 (11%), buprenorphine initiated for 106 (5%), and home induction buprenorphine kits given to 56 (3%). Following ED discharge, 237 patients (12%) had a visit within 14 days, 122 (6%) had ≥2 additional visits, and 207 (11%) received a subsequent buprenorphine prescription. Young, White, male patients were most likely to receive ED-OUD care. Patients who received ED-OUD care were more likely to have subsequent treatment engagement (adjusted rate ratio: 2.30, 95% confidence intervals: 1.62-3.27). Referrals were made less often than predicted for Black (-49%) or Hispanic/Latinx (-25%) patients. CONCLUSIONS: Initiating treatment for OUD in the ED was associated with increased engagement in outpatient addiction care.

Nudging Emergency Department-Initiated Addiction Treatment.

OBJECTIVES: When initiated in the Emergency Department (ED), medication for addiction treatment (MAT) with buprenorphine improves outcomes, increases engagement in addiction treatment and decreases the use of inpatient addiction treatment services. Unfortunately, initiating MAT in the ED is not yet standard practice. We assessed the impact of the addition of a multipart behavioral science-based intervention to increase opioid use disorder (OUD)-related treatments prescribed in the ED. METHODS: Our ED initiated a campaign to help ED faculty obtain their DEA-X waiver required to prescribe buprenorphine. In parallel, we implemented 2 ED-initiated buprenorphine treatment pathways. We then conducted a two-stage qualitative process informed by behavioral science to identify key barriers to physician use of the MAT protocol. Using these insights, we developed 4 behavioral science-based interventions. To assess the impact of the interventions on the number of OUD-related treatments per day among patients meeting the inclusion criteria we compared the number of OUD-related treatments per day before versus after the interventions began using t tests. Then, in our primary model, we estimated the causal effect of the behavioral interventions using a regression discontinuity in time approach. RESULTS: Across the entire year study period, there is an increase in OUD-related treatment after the interventions begin, driven by greater use of ambulatory referral orders. The unadjusted mean difference in any OUD treatments per day pre- versus post-intervention increased by 0.80 (95% confidence interval [CI]: 0.04, 1.56; P = 0.039) whereas the number of ambulatory referral orders placed increased by 0.82 (95% CI: 0.48,1.16; P < 0.001). Using the 120-day study window and an ordinary least squares regression discontinuity in time model, the 4-part intervention increased the number of patients receiving any opioid treatment in the ED by 1.6 additional treatments per day (95% CI: 0.04, 3.19; P = 0.045). CONCLUSIONS: To support our protocol and increase the provision of ED-MAT, we implemented 1 patient-facing and 3 provider-facing interventions rooted in behavioral science principles. Our results show that this pack of behavioral science interventions increased the likelihood that ED providers offer MAT to patients with OUD.

The Vot-ER Healthy Democracy Campaign: A National Medical Student Competition to Increase Voting Access.

PROBLEM: Voting affords citizens a direct say in the leaders and policies that affect their health. However, less than 20% of eligible U.S. citizens have been offered the chance to register to vote at a government-funded agency like a hospital or clinic that provides Medicaid or Medicare services. Medical students are well positioned to increase voting access due to their interactions with multiple actors in health care settings, including patients, visitors, colleagues, and others. APPROACH: Vot-ER, a nonpartisan, nonprofit organization that aims to promote civic engagement in health care settings, launched the inaugural Healthy Democracy Campaign from July 20 to October 9, 2020. As part of this national, gamification-based competition, medical student captains were recruited to lead teams of health care trainees and professionals that helped eligible adults start the voter registration and/or mail-in ballot request process before the November 2020 elections. Post competition, medical student captains were surveyed about their motivations for participating and skills and knowledge gained. OUTCOMES: In total, 128 medical student captains at 80 medical schools in 31 states and the District of Columbia formed teams that helped 15,692 adults start the voter registration and/or mail-in ballot request process. Eighty-two (64.1%) captains responded to the post competition survey, representing 56 (70.0%) of the participating schools. The top-ranked motivation for participating in the campaign was the desire to address social and racial inequities (37, 45.1%). Respondents reported gaining skills and knowledge in several aspects of civic engagement, including community organizing (67, 81.7%) and voting rights (63, 76.8%). The majority of respondents planned to incorporate voter registration into their future practice (76, 92.7%). NEXT STEPS: Future Healthy Democracy Campaigns will aim to continue closing the voting access gap and promote the long-term inclusion of hands-on civic engagement in medical education and practice.

Get waivered remote: Nationwide, remote DEA-x waiver course in response to COVID-19.

PROBLEM: As of 2020, less than 5% of physicians in the United States have a drug enforcement administration-X waiver to prescribe buprenorphine. The coronavirus-2019 pandemic restricted in-person gatherings, including traditional drug enforcement administration-X waiver courses. As a result, in-person conferences have needed to adopt remote formats. Many programs identified a gap between educational delivery and the faculty skills required to deliver content remotely. APPROACH: To address the need for high-quality remote learning, Get Waivered designed and implemented a novel experience for clinicians, called Get Waivered Remote. An educational session was live-streamed via Zoom™. To foster interactivity, like in-person didactic conferences, participants were polled to facilitate discussion among presenters, learners, and facilitators during the broadcast. OUTCOMES: The RE-AIM framework was used for evaluation. Our program had a Reach encompassing 814 users that participated during the live-streamed event; Effectiveness with 73.79% reporting being somewhat familiar or very familiar with the practice of opioid dependency treatment with approved buprenorphine medications; Adoption with 95.15% reporting a favorable experience and 92.23% reporting it was similar or more enjoyable than their usual teaching; Implementation with 450 messages sent by 281 users to engage with presenters and other learners via Zoom chat in real time. NEXT STEPS: Get Waivered Remote provides a proof-of-concept that a broadcast with a concurrent, interactive remote learning platform is feasible, low cost, and simple to execute. Further study is required to assess the ability of our group to maintain this innovation and also to measure its impact on the treatment of opioid use disorder.

Beyond Buprenorphine: Models of Follow-up Care for Opioid Use Disorder in the Emergeny Department.

Recent evidence shows that emergency physicians (EP) can help patients obtain evidence-based treatment for Opioid Use Disorder by starting medication for addiction treatment (MAT) directly in the Emergency Department (ED). Many EDs struggle to provide options for maintenance treatment once patients are discharged from the ED. Health systems around the country are in need of a care delivery structure to link ED patients with OUD to care following initiation of buprenorphine. This paper reviews the three most common approaches to form effective partnerships between EDs and primary care/addiction medicine services: the Project Alcohol and Substance Abuse Services and Referral to Treatment (ASSERT) model, Bridge model, and ED-Bridge model.The ASSERT Model is characterized by peer educators or community workers in the ED directly referring patients suffering from OUD in the ED to local addiction treatment services. The Bridge model encourages prescribing physicians in an ED to screen patients for OUD, provide a short-term prescription for buprenorphine, and then refer the patient directly to an outpatient Bridge Clinic that is co-located in the same hospital but is a separate from the ED. This Bridge Clinic is staffed by addiction trained physicians and mid-level clinicians. The ED-Bridge model employs physicians trained in both emergency medicine and addiction medicine to serve within the ED as well as in the follow up addiction clinic.Distinct from the Bridge Clinic model above, EPs in the ED-Bridge model are both able to screen at-risk patients in the ED, often starting treatment, and to longitudinally follow patients in a regularly scheduled addiction clinic. This paper provides examples of these three models as well as implementation and logistical details to support a health system to better address OUD in their communities.

Emergency Department Clinicians' Attitudes Toward Opioid Use Disorder and Emergency Department-initiated Buprenorphine Treatment: A Mixed-Methods Study.

INTRODUCTION: Emergency department (ED) visits related to opioid use disorder (OUD) have increased nearly twofold over the last decade. Treatment with buprenorphine has been demonstrated to decrease opioid-related overdose deaths. In this study, we aimed to better understand ED clinicians' attitudes toward the initiation of buprenorphine treatment in the ED. METHODS: We performed a mixed-methods study consisting of a survey of 174 ED clinicians (attending physicians, residents, and physician assistants) and semi-structured interviews with 17 attending emergency physicians at a tertiary-care academic hospital. RESULTS: A total of 93 ED clinicians (53% of those contacted) completed the survey. While 80% of respondents agreed that buprenorphine should be administered in the ED for patients requesting treatment, only 44% felt that they were prepared to discuss medication for addiction treatment. Compared to clinicians with fewer than five years of practice, those with greater experience were less likely to approve of ED-initiated buprenorphine. In our qualitative analysis, physicians had differing perspectives on the role that the ED should play in treating OUD. Most physicians felt that a buprenorphine-based intervention in the ED would be feasible with institutional support, including training opportunities, protocol support within the electronic health record, counseling and support staff, and a robust referral system for outpatient follow-up. CONCLUSION: ED clinicians' perception of buprenorphine varied by years of practice and training level. Most ED clinicians did not feel prepared to initiate buprenorphine in the ED. Qualitative interviews identified several addressable barriers to ED-initiated buprenorphine.