Policies for type 2 diabetes and non-communicable disease management during the COVID-19 pandemic in Kenya and Tanzania: a desk review and views of decision-makers.

BACKGROUND: The COVID-19 pandemic caused disruptions in care that adversely affected the management of non-communicable diseases (NCDs) globally. Countries have responded in various ways to support people with NCDs during the pandemic. This study aimed to identify policy gaps, if any, in the management of NCDs, particularly diabetes, during COVID-19 in Kenya and Tanzania to inform recommendations for priority actions for NCD management during any future similar crises. METHODS: We undertook a desk review of pre-existing and newly developed national frameworks, policy models and guidelines for addressing NCDs including type 2 diabetes. This was followed by 13 key informant interviews with stakeholders involved in NCD decision-making: six in Kenya and seven in Tanzania. Thematic analysis was used to analyse the documents. RESULTS: Seventeen guidance documents were identified (Kenya=10; Tanzania=7). These included pre-existing and/or updated policies/strategic plans, guidelines, a letter, a policy brief and a report. Neither country had comprehensive policies/guidelines to ensure continuity of NCD care before the COVID-19 pandemic. However, efforts were made to update pre-existing documents and several more were developed during the pandemic to guide NCD care. Some measures were put in place during the COVID-19 period to ensure continuity of care for patients with NCDs such as longer supply of medicines. Inadequate attention was given to monitoring and evaluation and implementation issues. CONCLUSION: Kenya and Tanzania developed and updated some policies/guidelines to include continuity of care in emergencies. However, there were gaps in the documents and between policy/guideline documents and practice. Health systems need to establish disaster preparedness plans that integrate attention to NCD care to enable them to better handle severe disruptions caused by emergencies such as pandemics. Such guidance needs to include contingency planning to enable adequate resources for NCD care and must also address evaluation of implementation effectiveness.

Multilevel Interventions to Improve Colorectal Cancer Screening in an Urban Native American Community: A Pilot Randomized Clinical Trial.

Native Americans have the highest burden of colorectal cancer (CRC) and the lowest rates of CRC screening across the United States.1 The disparities in CRC screening were made worse during the pandemic, creating an unmet need to implement evidence-based, multilevel interventions to improve CRC screening uptake. This can be achieved through an organized outreach program with identification of screen-eligible individuals using health records from the clinic; and a screening program with the following: (1) a mailed invitation, (2) a package of materials so patients can complete a fecal immunochemical test (FIT) kit from their homes, (3) reminder calls and a letter, and (4) navigation to a diagnostic colonoscopy.2-5 We conducted a pilot randomized controlled trial of a program of outreach vs usual care for completion of CRC screening at an urban clinic serving the Native American community. Applying the Consolidated Framework for Implementation Research (CFIR),6 we also conducted patient and provider interviews to understand barriers and facilitators to the organized program and CRC screening in general.

Applying i-PARIHS to Identify Emerging Innovations in Hospital Discharge Decision Making in Response to System Stress: A Qualitative Study.

Background: The purpose of this qualitative study was to use a Learning Health System approach to identify factors influencing the emergence of innovation in rehabilitation hospital discharge decision-making during the Coronavirus 2019 (COVID-19) pandemic. Methods: Rehabilitation clinicians were recruited from the Veterans Affairs Health Care System and participated in individual semi-structured interviews guided by the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework. Data were analyzed using a rapid qualitative, deductive team-based approach informed by directed content analysis. Results: Twenty-three rehabilitation clinicians representing physical (N = 11) and occupational therapy (N = 12) participated in the study. Three primary themes were generated: (1) Recipients: innovations emerged as approaches to communicating discharge recommendations changed (in-person to virtual) and strong patient/family preferences to discharge to the home challenged collaborative goal setting; (2) Context: the ability of rehabilitation clinicians to innovate and the form of innovations were influenced by the broader hospital system, interdisciplinary team dynamics, and policy fluctuations; (3) Innovation: emerging innovations in discharge processes included perceived increases in team collaboration, shifts in caseload prioritization, and alternative options for post-acute care. Conclusions: Our findings reinforce that rehabilitation clinicians developed innovative strategies to quickly adapt to multiple systems-level factors that were changing in the face of the COVID-19 pandemic. Future research is needed to assess the impact of innovations, remediate unintended consequences, and evaluate the implementation of promising innovations to respond to emerging healthcare delivery needs more rapidly.

The impact of trauma-informed design on psychological well-being in homeless shelters.

Trauma-informed design is an emerging concept that combines elements of interior design, environmental psychology, and clinical psychology. Previous reports describe the potential impact of the physical space and design of homeless shelters on positive psychological outcomes (Pable, 2012). However, there is little known research on these outcomes. This article provides preliminary support for positive outcomes through a program evaluation of a trauma-informed design of resident bedrooms at two homeless shelters in North Carolina. Residents (n = 61) were asked to take a presurvey (before room design) and postsurvey (after design) that assessed their experiences of preparedness, hopefulness, and safety. Among those who completed both pre and postsurveys (n = 43), there was a statistically significant improvement in all three factors following the design, with the largest effect sizes for safety and total score average. Additionally, qualitative findings indicate participants felt the design updates increased their experiences of dignity (n = 17) and safety (n = 13), with some indicating increased feelings of hope (n = 4). We discuss implications for other homeless shelters, as well as similar institutions that support people in transitional housing. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

"It's my frenemy": A qualitative exploration of knowledge and perceptions of fentanyl use during the COVID-19 pandemic in people who use drugs at a syringe services program in Philadelphia, PA.

Background: Exacerbated by the COVID-19 pandemic and the proliferation of fentanyl and fentanyl analogs, overdose deaths have surged in the United States, making it important to understand how individuals who use drugs experience and perceive the risks of fentanyl use and how it has changed during the COVID-19 pandemic. Methods: Twenty clients from a Philadelphia syringe services program completed a questionnaire and in-depth interview about their fentanyl experiences from January to March 2021. These interviews were transcribed and analyzed using thematic analysis methods. Results: Sixty percent of participants were female and racial/ethnic minority. Participants indicated they believed fentanyl use accounted for most Philadelphia opioid-related overdoses and understood that fentanyl was different from other opioids. Fentanyl use was characterized as "all-consuming" by taking over lives and inescapable. While most perceived their risk of fentanyl overdose as high, there was low interest in and reported use of harm reduction strategies such as fentanyl test strips. The COVID-19 pandemic was noted to have negative effects on fentanyl availability, use and overdose risk, as well as mental health effects that increase drug use. Conclusions: The divide between perceived risk and uptake of protective strategies could be driven by diminished self-efficacy as it relates to acting on and engaging with resources available at the syringe services program and represents a potential intervention target for harm reduction intervention uptake. But the COVID-19 pandemic has exacerbated risks due to fentanyl use, making an effective, accessible, and well-timed intervention important to address the disconnect between perceived overdose risk and use of preventive behaviors.

Alcohol use disorder pharmacotherapy and treatment in primary care (ADaPT-PC) trial: Impact on identified barriers to implementation.

Background: A minority of individuals meeting diagnostic criteria for alcohol use disorders (AUD) receive any type of formal treatment. Developing options for AUD treatment within primary care settings is imperative to increase treatment access. A multi-faceted implementation intervention including provider and patient education, clinician reminders, development of local champions and ongoing facilitation was designed to enhance access to AUD pharmacotherapy in primary care settings at three large Veterans Health Administration (VHA) facilities. This qualitative study compared pre-implementation barriers to post-implementation barriers identified via provider interviews to identify those barriers addressed and not addressed by the intervention to better understand the limited impact of the intervention. Methods: Following the nine-month implementation period, primary care providers at the three participating facilities took part in qualitative interviews to collect perceptions regarding which pre-implementation barriers had and had not been successfully addressed by the intervention. Participants included 20 primary care providers from three large VHA facilities. Interviews were coded using common coding techniques for qualitative data using the Consolidated Framework for Implementation Research (CFIR) codebook. Summary reports were created for each CFIR construct for each facility and the impact of each CFIR construct on implementation was coded as positive, neutral, or negative. Results: Some barriers identified during pre-implementation interviews were no longer identified as barriers in the post-implementation interviews. These included Relative Advantage, Relative Priority, and Knowledge & Beliefs about the Innovation. However, Compatibility, Design Quality & Packaging, and Available Resources remained barriers at the end of the implementation period. No substantial new barriers were identified. Conclusions: The implementation intervention appears to have been successful at addressing barriers that could be mitigated with traditional educational approaches. However, the intervention did not adequately address structural and organizational barriers to implementation. Recommendations for enhancing future interventions are provided.

Practice Considerations for Adapting in-Person Groups to Telerehabilitation.

The Coronavirus-2019 (COVID-19) pandemic has shifted research and healthcare system priorities, stimulating literature on implementation and evaluation of telerehabilitation for a variety of patient populations. While there is substantial literature on individual telerehabilitation, evidence about group telerehabilitation remains limited despite its increasing use by rehabilitation providers. Therefore, the purpose of this manuscript is to describe our expert team's consensus on practice considerations for adapting in-person group rehabilitation to group telerehabilitation to provide rapid guidance during a pandemic and create a foundation for sustainability of group telerehabilitation beyond the pandemic's end.

Fluctuations in barriers to medication treatment for opioid use disorder prescribing over the course of a one-year external facilitation intervention.

BACKGROUND: The Veterans Health Administration (VHA) is invested in expanding access to medication treatment for opioid use disorder (MOUD) to save lives. Access varies across VHA facilities and, thus, requires implementation strategies to promote system-wide adoption of MOUD. We conducted a 12-month study employing external facilitation that targeted MOUD treatment among low-adopting VHA facilities. In this study, we sought to evaluate the patterns of perceived barriers over 1 year of external implementation facilitation using the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework. METHODS: We randomly selected eight VHA facilities from the bottom quartile of the proportion of Veterans with an OUD diagnosis receiving MOUD (< 21%). The 1-year external implementation intervention included developmental evaluation to tailor the facilitation, an on-site visit, and monthly facilitation calls. Facilitators recorded detailed notes for each call on a structured template. Qualitative data was analyzed by coding and mapping barriers to the constructs in the i-PARIHS framework (Innovation, Recipients, Context). We identified emerging themes within each construct by month. RESULTS: Barriers related to the Innovation, such as provider perception of the need for MOUD in their setting, were minimal throughout the 12-month study. Barriers related to Recipients were predominant and fluctuated over time. Recipient barriers were common during the initial months when providers did not have the training and waivers necessary to prescribe MOUD. Once additional providers (Recipients) were trained and waivered to prescribe MOUD, Recipient barriers dropped and then resurfaced as the facilities worked to expand MOUD prescribing to other clinics. Context barriers, such as restrictions on which clinics could prescribe MOUD and fragmented communication across clinics regarding the management of patients receiving MOUD, emerged more prominently in the middle of the study. CONCLUSIONS: VHA facilities participating in 12-month external facilitation interventions experienced fluctuations in barriers to MOUD prescribing with contextual barriers emerging after a facilitated reduction in recipient- level barriers. Adoption of MOUD prescribing in low-adopting VHA facilities requires continual reassessment, monitoring, and readjustment of implementation strategies over time to meet challenges. Although i-PARIHS was useful in categorizing most barriers, the lack of conceptual clarity was a concern for some constructs.

Long-acting buprenorphine vs. naltrexone opioid treatments in CJS-involved adults (EXIT-CJS).

The EXIT-CJS (N = 1005) multisite open-label randomized controlled trial will compare retention and effectiveness of extended-release buprenorphine (XR-B) vs. extended-release naltrexone (XR-NTX) to treat opioid use disorder (OUD) among criminal justice system (CJS)-involved adults in six U.S. locales (New Jersey, New York City, Delaware, Oregon, Connecticut, and New Hampshire). With a pragmatic, noninferiority design, this study hypothesizes that XR-B (n = 335) will be noninferior to XR-NTX (n = 335) in retention-in-study-medication treatment (the primary outcome), self-reported opioid use, opioid-positive urine samples, opioid overdose events, and CJS recidivism. In addition, persons with OUD not eligible or interested in the RCT will be recruited into an enhanced treatment as usual arm (n = 335) to examine usual care outcomes in a quasi-experimental observational cohort.

Sexual orientation and gender identity disparities in co-occurring depressive symptoms and probable substance use disorders in a national cohort of young adults.

This study examined sexual orientation and gender identity differences in co-occurring depressive symptoms and substance use disorders (SUDs) among young adults in the Growing Up Today Study national cohort (n = 12,347; ages 20-35; 93% non-Hispanic white). Self-administered questionnaires assessed recent co-occurring depressive symptoms and probable nicotine dependence, alcohol use disorder, and drug use disorder. Multinomial logistic regressions with generalized estimating equations quantified differences in prevalences of depressive symptoms only, SUDs only, and co-occurrence, among sexual minorities (mostly heterosexual; lesbian, gay, and bisexual [LGB]) compared to completely heterosexual participants, and gender minorities compared to cisgender participants. Analyses stratified by sex assigned at birth revealed sexual minorities evidenced greater odds of co-occurrence than their completely heterosexual counterparts (assigned female AORs: 3.11-9.80, ps < 0.0001; assigned male AORs: 2.90-4.87, ps < 0.001). Sexual orientation differences in co-occurrence were pronounced among LGB participants assigned female at birth who evidenced nearly 10 times the odds of co-occurring depressive symptoms with nicotine dependence and drug use disorders than did heterosexual participants assigned female at birth. Relationships between gender identity and co-occurrence were generally weaker, possibly due to low power. Gender minorities assigned male at birth, however, evidenced greater odds of co-occurring depressive symptoms and alcohol use disorders (AOR 2.75, p = 0.013) than their cisgender counterparts. This study adds to the limited research quantifying sexual orientation or gender identity differences in recent co-occurring depressive symptoms and SUDs among young adults and suggests sexual and gender minority young adults should be prioritized in prevention and treatment of co-occurring depression and SUDs.

Early impacts of a multi-faceted implementation strategy to increase use of medication treatments for opioid use disorder in the Veterans Health Administration.

BACKGROUND: Despite the risk of negative sequelae from opioid use disorder (OUD) and clinical guidelines for the use of effective medication treatment for OUD (M-OUD), many Veterans Health Administration (VHA) providers and facilities lag in providing M-OUD. An intensive external facilitation intervention may enhance uptake in low-adopting VHA facilities by engaging stakeholders from multiple clinical settings within a facility (e.g., mental health, primary care, pain specialty clinic, substance use disorder clinics). Our study identified pre-intervention determinants of implementation through qualitative interviews, described strategies employed during the first 6 months of intensive external facilitation, and explored patterns of implementation determinants in relation to early outcomes. METHODS: Guided by the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework, we interviewed stakeholders at low-adopting VHA facilities prior to external facilitation, employed a rapid qualitative analytic process, presented findings during facility visits, and collaboratively created facilitation action plans to achieve goals set by the facilities that would increase M-OUD uptake. The primary outcome was the Substance Use Disorder (SUD)-16, which is a VHA facility-level performance metric consisting of the percent of patients receiving M-OUD among those with an OUD diagnosis. We examined the relationship between pre-implementation factors and 6-month SUD-16 outcomes. RESULTS: Across eight VHA facilities, we interviewed 68 participants. Implementation determinants included barriers and facilitators across innovation, context, and recipients constructs of i-PARIHS. Each facility selected goals based on the qualitative results. At 6 months, two facilities achieved most goals and two facilities demonstrated progress. The SUD-16 from baseline to 6 months significantly improved in two facilities (8.4% increase (95 % confidence interval [CI] 4.4-12.4) and 9.9% increase (95% CI 3.6-16.2), respectively). Six-month implementation outcomes showed that the extent to which M-OUD aligns with existing clinical practices and values was a primary factor at all facilities, with six of eight facilities perceiving it as both a barrier and facilitator. External health system barriers were most challenging for facilities with the smallest change in SUD-16. CONCLUSIONS: Early impacts of a multi-faceted implementation approach demonstrated a strong signal for positively impacting M-OUD prescribing in low-adopting VHA facilities. This signal indicates that external facilitation can influence adoption of M-OUD at the facility level in the early implementation phase. These short-term wins experienced by stakeholders may encourage continued adoption and long-term sustainability M-OUD.

"Sign Me Up, I'm Ready!": Helping Patients Prescribed Sleeping Medication Engage with Cognitive Behavioral Therapy for Insomnia (CBT-I).

OBJECTIVE/BACKGROUND: Cognitive behavioral therapy for insomnia (CBT-I) provides safe and effective insomnia care without the risk of harm associated with sleeping medications. Unfortunately, few patients with insomnia engage with CBT-I, with most using sedative hypnotics instead. This study conducted focus groups with patients with insomnia who were treated with sleeping medication, including older adults, women, and patients with chronic pain. The goal was to explore the perspectives of high-risk, CBT-I naïve patients on increasing access and engagement with CBT-I. PARTICIPANTS: Participants included 29 Veterans with insomnia who had been prescribed sleeping medication in the last year and had not previously engaged with CBT-I. METHODS: Semi-structured 90-min focus groups were used to 1) explore messages and appropriate channels for a CBT-I social marketing campaign, 2) determine patient preferences for self-management CBT-I tools, and 3) determine patient opinions on alternative provider-delivered forms of CBT-I. Thematic analysis was used to identify conceptual themes. RESULTS: Three main themes were identified. First, patient education is necessary but not sufficient. Patients recommended multiple outreach attempts through multiple channels to motivate tired and overwhelmed insomnia patients to engage with CBT-I. Second, patients gravitated toward a stepped-care approach. Most would start with self-management CBT-I tools, moving on to provider-delivered CBT-I if needed. Finally, patients appreciated being able to choose from a menu of CBT-I delivery options and would use multiple options simultaneously. CONCLUSIONS: These findings suggest promising opportunities to increase the use of CBT-I for high-risk patients through patient education and provision of self-management CBT-I tools.

Exploring the Meaning of Cognitive Behavioral Therapy for Insomnia for Patients with Chronic Pain.

OBJECTIVE: Insomnia is one of the most common, persistent, and distressing symptoms associated with chronic pain. Cognitive behavioral therapy for insomnia (CBT-I) is the firstline treatment for insomnia, but patient preferences and perspectives about CBT-I within the context of chronic pain are unknown. The current qualitative study sought to understand the experience of CBT-I among patients with chronic pain, including aspects of CBT-I that were found to be difficult (e.g., pain as a specific barrier to adherence/dropout), changes in sleep and pain functioning after CBT-I, and aspects of CBT-I that were appreciated. DESIGN: Qualitative semistructured interviews. METHODS: We conducted individual semistructured interviews with 17 veterans with chronic pain and insomnia who had recently participated in CBT-I, as well as their CBT-I therapists, and used thematic analysis to identify conceptual themes. RESULTS: Results revealed that patients and CBT-I therapists found changing sleep habits during CBT-I challenging due to anxiety and temporary increases in fatigue, but did not identify major pain-related barriers to adhering to CBT-I recommendations; patients experienced better sleep, mood, energy, and socialization after CBT-I despite minimal changes in pain intensity; and patients highly valued CBT-I as a personalized treatment for sleep and strongly recommended it for other patients with chronic pain. CONCLUSIONS: Findings of improved sleep and functional outcomes support efforts to incorporate CBT-I into chronic pain treatment, including educating patients and providers about the strong feasibility of improving sleep and quality of life despite ongoing pain.

"You're Missing Out on Something Great": Patient and Provider Perspectives on Increasing the Use of Cognitive Behavioral Therapy for Insomnia.

Objective/Background: Cognitive behavioral therapy for insomnia (CBT-I) is the most effective treatment for insomnia but is severely underutilized. One of the key reasons for underuse is lack of knowledge among patients and primary care providers, but effective methods and materials for increasing knowledge are unknown. This study conducted in-depth interviews with CBT-I patients and their CBT-I providers to explore their perceptions on increasing utilization of CBT-I. Participants: Participants included patients who had engaged in CBT-I (N = 17) and CBT-I providers (N = 7). Methods: Semistructured interviews were used to explore the CBT-I referral process, recommendations for increasing uptake of CBT-I, and opinions on CBT-I self-management, with thematic analysis used to identify conceptual themes. Findings were compared and contrasted across patients who completed versus prematurely discontinued therapy and patients versus CBT-I providers. Results: Three main themes of referral, selling, and delivery were identified. Regarding referral, patients had not heard of nor requested CBT-I. Proactive outreach is crucial in populations in which insomnia is so common that it becomes normalized. For selling, patients and CBT-I providers had powerful testimonials that could be used to "sell" treatment using a peer-to-peer approach. Finally, for delivery, patients and CBT-I providers were ambivalent about alternative delivery formats and emphasized the need for personal contact. Although technology may be useful in advertising and delivering CBT-I, it will be important to ensure that these approaches promote rather than discourage engagement in CBT-I. Conclusions: These findings suggest promising opportunities to increase the use of CBT-I, including direct-to-consumer marketing.

Stress, Coping, and Context: Examining Substance Use Among LGBTQ Young Adults With Probable Substance Use Disorders.

OBJECTIVE: The authors qualitatively examined how lesbian, gay, bisexual, transgender, and queer (LGBTQ) young adults with probable substance use disorders conceptualized their substance use vis-à-vis their LGBTQ identities. METHODS: Individual, in-depth, semistructured interviews were conducted with 59 LGBTQ young adults (ages 21-34) who were participants in a larger longitudinal cohort study and who met criteria for a probable substance use disorder. Data were analyzed via iterative, thematic analytic processes. RESULTS: Participants' narratives highlighted processes related to minority stress that shape substance use, including proximal LGBTQ stressors (e.g., self-stigma and expectations of rejection) and distal LGBTQ stressors (e.g., interpersonal and structural discrimination) and associated coping. Participants also described sociocultural influences, including the ubiquitous availability of substances within LGBTQ social settings, as salient contributors to their substance use and development of substance use disorders. Participants who considered themselves transgender or other gender minorities, all of whom identified as sexual minorities, described unique stressors and coping at the intersection of their minority identities (e.g., coping with two identity development and disclosure periods), which shaped their substance use over time. CONCLUSIONS: Multilevel minority stressors and associated coping via substance use in adolescence and young adulthood, coupled with LGBTQ-specific sociocultural influences, contribute to the development of substance use disorders among some LGBTQ young adults. Treatment providers should address clients' substance use vis-à-vis their LGBTQ identities and experiences with related stressors and sociocultural contexts and adopt culturally humble and LGBTQ-affirming treatment approaches. Efforts to support LGBTQ youths and young adults should focus on identifying ways of socializing outside of substance-saturated environments.

Sexual orientation and gender identity disparities in substance use disorders during young adulthood in a United States longitudinal cohort.

BACKGROUND: This study examined associations of sexual orientation and gender identity with prevalence of substance use disorders (SUDs) and co-occurring multiple SUDs in the past 12-months during young adulthood in a United States longitudinal cohort. METHODS: Questionnaires self-administered in 2010 and 2015 assessed probable past 12-month nicotine dependence, alcohol abuse and dependence, and drug abuse and dependence among 12,428 participants of an ongoing cohort study when they were ages 20-35 years. Binary or multinomial logistic regressions using generalized estimating equations were used to estimate differences by sexual orientation and gender identity in the odds of SUDs and multiple SUDs, stratified by sex assigned at birth. RESULTS: Compared with completely heterosexuals (CH), sexual minority (SM; i.e., mostly heterosexual, bisexual, lesbian/gay) participants were generally more likely to have a SUD, including multiple SUDs. Among participants assigned female at birth, adjusted odds ratios (AORs) for SUDs comparing SMs to CHs ranged from 1.61 to 6.97 (ps<.05); among participants assigned male at birth, AORs ranged from 1.30 to 3.08, and were statistically significant for 62% of the estimates. Apart from elevated alcohol dependence among gender minority participants assigned male at birth compared with cisgender males (AOR: 2.30; p < .05), gender identity was not associated with prevalence of SUDs. CONCLUSIONS: Sexual and gender minority (SGM) young adults disproportionately evidence SUDs, as well as co-occurring multiple SUDs. Findings related to gender identity and bisexuals assigned male at birth should be interpreted with caution due to small sample sizes. SUD prevention and treatment efforts should focus on SGM young adults.

Implementing alcohol use disorder pharmacotherapy in primary care settings: a qualitative analysis of provider-identified barriers and impact on implementation outcomes.

BACKGROUND: Despite the high prevalence of alcohol use disorders (AUDs), in 2016, only 7.8% of individuals meeting diagnostic criteria received any type of AUD treatment. Developing options for treatment within primary care settings is imperative to increase treatment access. As part of a trial to implement AUD pharmacotherapy in primary care settings, this qualitative study analyzed pre-implementation provider interviews using the Consolidated Framework for Implementation Research (CFIR) to identify implementation barriers. METHODS: Three large Veterans Health Administration facilities participated in the implementation intervention. Local providers were trained to serve as implementation/clinical champions and received external facilitation from the project team. Primary care providers received a dashboard of patients with AUD for case identification, educational materials, and access to consultation from clinical champions. Veterans with AUD diagnoses received educational information in the mail. Prior to the start of implementation activities, 24 primary care providers (5-10 per site) participated in semi-structured interviews. Transcripts were analyzed using common coding techniques for qualitative data using the CFIR codebook Innovation/Intervention Characteristics, Outer Setting, Inner Setting, and Characteristics of Individuals domains. Number and type of barriers identified were compared to quantitative changes in AUD pharmacotherapy prescribing rates. RESULTS: Four major barriers emerged across all three sites: complexity of providing AUD pharmacotherapy in primary care, the limited compatibility of AUD treatment with existing primary care processes, providers' limited knowledge and negative beliefs about AUD pharmacotherapy and providers' negative attitudes toward patients with AUD. Site specific barriers included lack of relative advantage of providing AUD pharmacotherapy in primary care over current practice, complaints about the design quality and packaging of implementation intervention materials, limited priority of addressing AUD in primary care and limited available resources to implement AUD pharmacotherapy in primary care. CONCLUSIONS: CFIR constructs were useful for identifying pre-implementation barriers that informed refinements to the implementation intervention. The number and type of pre-implementation barriers identified did not demonstrate a clear relationship to the degree to which sites were able to improve AUD pharmacotherapy prescribing rate. Site-level implementation process factors such as leadership support and provider turn-over likely also interacted with pre-implementation barriers to drive implementation outcomes.

Patient perspectives on alcohol use disorder pharmacotherapy and integration of treatment into primary care settings.

Background: Evidence-based pharmacotherapies for alcohol use disorders (AUDs) are underutilized. This mixed-methods study reports supplementary findings from the alcohol use disorder pharmacotherapy and treatment in primary care (ADaPT-PC) implementation study at 3 Veterans Health Administration (VHA) hospital sites to understand why prescription rates did not increase following the ADaPT-PC intervention. Methods: Qualitative interviews (N = 30) were conducted in advance of the ADaPT-PC intervention to understand patients' pharmacotherapy attitudes among those in AUD treatment, with previous treatment experience, or who needed assistance with their alcohol use. Following the ADaPT-PC intervention, chart reviews from a random sample of patients with AUD or a most recent Alcohol Use Disorders Identification Test consumption questions (AUDIT-C) score >8, and no active AUD prescription, were conducted to determine the frequency of alcohol-related conversations (N = 455). Results: Most interviewed patients welcomed a discussion about their alcohol use and pharmacotherapy. Of the 15 medication-naïve patients interviewed, 6 stated that they would be willing to try pharmacotherapy, 5 stated that they were unlikely, 2 identified reservations, 1 said no, and 1 was not asked. Fifteen patients were either currently taking medications (n = 10) or had taken medication in the past (n = 7; 2 patients had past and current experience). Chart reviews indicated that although 66% of charts (n = 299) documented a discussion of their alcohol use with the provider, only 7.5% (n = 22) of individuals with an AUD diagnosis had a documented discussion of AUD pharmacotherapy, and only 5 received pharmacotherapy. Conclusion: Most interviewed patients were open to discussing AUD treatment, including discussions of pharmacotherapy, with their provider. From documented conversations about alcohol use to treatment options, medical records suggests a continuous narrowing of the number of patients engaged in alcohol-related consultations. Although some interviewed patients expressed reticence about initiating pharmacotherapy, these findings suggest that the treatment cascade may have a greater influence on the number of pharmacotherapy prescriptions than patients' preferences.

Multi-Sectoral Approach to Noncommunicable Disease Prevention Policy in Sub-Saharan Africa: A Conceptual Framework for Analysis.

Conceptual frameworks for health policy analysis guide investigations into interactions between institutions, interests, and ideas to identify how to improve policy decisions and outcomes. This review assessed constructs from current frameworks and theories of health policy analysis to (1) develop a preliminary synthesis of findings from selected frameworks and theories; (2) analyze relationships between elements of those frameworks and theories to construct an overarching framework for health policy analysis; and then, (3) apply that overarching framework to analyze tobacco control policies in Togo and in South Africa. This Comprehensive Framework for Multi-Sectoral Approach to Health Policy Analysis has 4 main constructs: context, content, stakeholders, and strategies. When applied to analyze tobacco control policy processes in Togo and in South Africa, it identified a shared goal in both countries to have a policy content that is compliant with the provisions of international tobacco treaties and differences in strategic interactions between institutions (e.g., tobacco industry, government structures) and in the political context of tobacco control policy process. These findings highlight the need for context-specific political mapping identifying the interests of all stakeholders and strategies for interaction between health and other sectors when planning policy formulation or implementation.

Emergency Department Utilization for Substance Use-Related Disorders and Assessment of Treatment Facilities in New York State, 2011-2013.

BACKGROUND: Annually, 1.8 million New York (NY) residents experience substance use disorders (SUDs). Even though emergency departments (EDs) continue to experience high numbers of SUD-related visits, only 15% receive treatment. OBJECTIVES: This study estimates hospital-based EDs rates for SUDs in the State of New York. Also, the geographic distribution of substance use treatment centers and EDs are mapped to correlate utilization with access to care. METHODS: The 2011-2013 Healthcare Cost and Utilization Project's NY State Emergency Department Database provided information on utilization of services in EDs, charges, diagnoses, and discharge, as well as patient demographic variables. All patients within NY who had visited the ED for SUDs comprised the study population. Geographic mapping of EDs and substance abuse treatment centers at the county-level is based on data from the National Emergency Department Inventory and National Survey of Substance Abuse Treatment Services, respectively. RESULTS: A total of 492,419 ED visits for SUDs were reported through 2011-2013. Despite NY's Medicaid expansion in 2012, ED visits increased in 2013. About $856 million was spent in treating SUDs in EDs, with average charge of $1,764 per visit. Conclusions/Importance: Alcohol and drug-induced mental disorders are increasingly prevalent in New York's EDs. There is a need to develop health policies and programs to improve access to care for SUDs in urban states.