Optimizing evidence-based practice implementation: a case study on simulated patient protocols in long-term opioid therapy.

BACKGROUND: Substantial work has been done to update or create evidence-based practices (EBPs) in the changing health care landscape. However, the success of these EBPs is limited by low levels of clinician implementation. OBJECTIVE: The goal of this study is to describe the use of standardized/simulated patient/person (SP) methodology as a framework to develop implementation bundles to increase the effectiveness, sustainability, and reproducibility of EBPs across health care clinicians. DESIGN: We observed 12 clinicians' first-time experiences with six unique decision-making algorithms, developed previously using rigorous Delphi methods, for use with patients exhibiting concerning behaviors associated with long-term opioid therapy (LTOT) for chronic pain. Clinicians were paired with two SPs trained to portray individuals with one of the concerning behaviors addressed by the algorithms in a telehealth environment. The SP evaluations were followed by individual interviews, guided by the Consolidated Framework for Implementation Research (CFIR), with each of the clinician participants. PARTICIPANTS: Twelve primary care clinicians and 24 SPs in Western Pennsylvania. MAIN MEASUREMENT: The primary outcome was identifying likely facilitators for the successful implementation of the EBP using the SP methodology. Our secondary outcome was to assess the feasibility of using SPs to illuminate likely implementation barriers and facilitators. RESULTS: The SP portrayal illuminated factors that were pertinent to address in the implementation bundle. SPs were realistic in their portrayal of patients with concerning behaviors associated with LTOT for chronic pain, but clinicians also noted that their patients in practice may have been more aggressive about their treatment plan. CONCLUSIONS: SP simulation provides unique opportunities for obtaining crucial feedback to identify best practices in the adoption of new EBPs for high-risk patients. SETTING: Zoom simulated patient evaluations.

Co-delivery of HIV pre-exposure prophylaxis (PrEP) and HIV testing among publicly insured adolescents and young adults (AYA) receiving medication for opioid use disorder (MOUD).

BACKGROUND: Low rates of HIV pre-exposure prophylaxis (PrEP) prescribing contribute to the disproportionate burden of HIV in the United States. Among adolescent and young adults (AYA) with opioid use disorder, HIV testing and PrEP co-prescription rates are poorly characterized. METHODS: We performed a retrospective analysis involving deidentified data from Philadelphia's Medicaid beneficiaries ages 16-29 years who were prescribed medication for opioid use disorder (MOUD) from 2015 to 2020 and continuously Medicaid-enrolled for ≥6 months prior to that prescription. After identifying the presence of a qualifying diagnosis signifying a PrEP indication, we examined the outcome of appropriate PrEP co-prescriptions and HIV testing using generalized estimating equations (GEE) modeling. RESULTS: We identified 795 AYA Medicaid beneficiaries with 1269 qualified treatment episodes. We calculated a PrEP prescribing rate of 29.47 per 1000 person-years among AYA receiving MOUD. The HIV testing rate was 63.47 per 1000 person-years among AYA receiving MOUD. GEE modeling revealed that individuals receiving methadone were more likely (aOR=2.62, 95% CI=1.06-6.49) to receive HIV testing within 6 months after a PrEP-qualifying diagnosis compared to those receiving other MOUD medications. Those who only saw outpatient behavioral health providers were less likely (aOR=0.48, 95% CI=0.24-0.99) to have received an HIV test within 6 months after the PrEP-qualifying diagnosis compared to those receiving inpatient behavioral health services. CONCLUSIONS: Co-prescription of PrEP and HIV testing among AYA receiving MOUD was rare in this large urban publicly insured population. Interventions are needed to increase HIV prevention services for this key population of AYA at risk for HIV infection.

A Simulated Patient Protocol for Implementing Evidence-Based Practices in Health Care Delivery.

Background: Substantial work has been done to update or create evidence-based practices (EBPs) in the changing health care landscape. However, the success of these EBPs is limited by low levels of clinician implementation. The goal of this study is to describe the use of simulated patient (SP) methodology as a framework to develop implementation bundles to increase the effectiveness, sustainability, and reproducibility of EBPs across health care clinicians. The primary outcome was identifying likely facilitators for the successful implementation of EBP. Our secondary outcome was the assess the feasibility of using SPs to illuminate likely implementation barriers and facilitators. Methods: We observed 12 primary care clinicians' first-time experiences with six unique decision-making algorithms for use with patients exhibiting concerning behaviors associated with long-term opioid therapy (LTOT) for chronic pain over Zoom. Each clinician was paired with two simulated patients trained to portray individuals with one of the concerning behaviors addressed by the algorithms. The Standardized Patient-evaluations were followed by CFIR guided one-on-one interviews with the clinicians. Results: The SP portrayal illuminated factors that were pertinent to address in the implementation bundle. SPs were realistic in their portrayal of patients with concerning behaviors associated with LTOT for chronic pain, but clinicians also noted that their patients in practice may have been more aggressive about their treatment plan. Conclusions: SP simulation provides unique opportunities for obtaining crucial feedback to identify best practices in the adoption of new EBPs for high-risk patients.

Implementation of Substance Use Services to Justice-Involved Youth: Examining Barriers, Facilitators, and Best Practices.

Justice-involved youth are known to be at elevated risk of substance use disorder (SUD). This review examines literature published over a 10-year period and summarizes evidence-based practices for screening, treatment, and linkage to care for justice-involved youth as well as barriers and facilitators that may arise during implementation. Strategies to incorporate a health equity lens and trauma-informed approaches are discussed. Despite high prevalence of substance use and research showing that treatment reduces recidivism, few juvenile justice systems universally screen and treat youth with SUD. There is limited developmentally appropriate guidance available for those seeking to better address substance use in juvenile justice settings. This review highlights gaps in the literature, which must be addressed to increase access to treatment and improve outcomes for this vulnerable youth population.

"No Excuses Anymore": Substance Use Screening and Treatment for Justice-involved Youth.

OBJECTIVE: The aim of this study was to present best practices for substance use disorder (SUD) screening and treatment in the juvenile justice setting. METHODS: Semistructured qualitative interviews, informed by the Capability-Opportunity-Motivation-Behavior Model, were conducted with medical and behavioral health providers with experience caring for justice-involved youth. Interviews were analyzed using thematic and content analysis to elucidate best practices and identify facilitators and barriers affecting implementation of evidence-based substance use screening and treatment. RESULTS: We interviewed 14 participants from 12 unique institutions and 9 states. All participants described the populations in their facilities as predominately male and minoritized, with substance use being an exceedingly common problem. Eight main themes emerged from analysis of the barriers and facilitators discussed by participants. These included the importance of (1) ensuring substance use-specific training for all team members, (2) integrating medical and behavioral health care, (3) addressing staff reticence and stigma, (4) building an institutional culture that supports screening and treatment, (5) dedicating adequate resources with respect to time, staffing, and funding, (6) formalizing and standardizing screening and treatment protocols, (7) engaging youth using trauma-informed approaches that emphasize youth strengths and autonomy, and (8) collaborating with multidisciplinary teams and community partners to maximize linkage to follow-up care after release. CONCLUSIONS: Our findings highlight an urgent need for improved implementation of evidence-based, developmentally appropriate substance use treatment for justice-involved youth. Although the majority of participants screen youth, they described variable implementation of behavioral health interventions and limited provision of on-site withdrawal management and treatment using medications for SUD.

A Call to Action: Integration of Buprenorphine Prescribing Into the Care of Persons With Human Immunodeficiency Virus and Opioid Use Disorder.

During the coronavirus disease 2019 (COVID-19) pandemic, we also experienced a worsening opioid overdose epidemic. Untreated opioid use disorder (OUD) in persons with human immunodeficiency virus (HIV) is associated with worse HIV-related outcomes. Buprenorphine is a safe, evidence-based medication for OUD and is effective in reducing opioid craving and overdose and improving outcomes along the HIV care continuum. Despite the longstanding evidence supporting the benefits of buprenorphine, there remains an implementation gap in the uptake of buprenorphine prescribing in HIV care settings. To improve integration of OUD care and HIV primary care, we recommend (1) all HIV clinicians obtain a buprenorphine waiver, (2) teaching on OUD should be integrated into infectious diseases and HIV continuing medical education, and (3) previously validated models of integrated care should be leveraged to urgently expand access to buprenorphine for persons with HIV and OUD.

Inpatient Addiction Medicine Consultation Service Impact on Post-discharge Patient Mortality: a Propensity-Matched Analysis.

BACKGROUND: Inpatient addiction medicine consultation services (AMCS) have grown rapidly, but there is limited research of their impact on patient outcomes. OBJECTIVE: To examine whether AMCS is associated with all-cause mortality and hospital utilization post-discharge. DESIGN: This was a propensity-score-matchedcase-control study from 2018 to 2020. PARTICIPANTS: The intervention group included patients referred to the AMCS from October 2018 to March 2020. Matched control participants included patients hospitalized from October 2017 to September 2018 at an urban academic hospital with a large suburban and rural catchment area. MAIN MEASURES: The effect of treatment was estimated as the difference between the proportion of subjects experiencing the event (7-day and 30-day readmission, emergency department visits, and mortality within 90 days) for each group in the matched sample. KEY RESULTS: There were 711 patients in the intervention group and 2172 patients in the control group. The most common substance use disorders among the intervention group were primary alcohol use disorder (n=181; 25.5%) and primary opioid use disorder (n=175, 24.6%) with over a third with polysubstance use (n=257, 36.1%). Intervention patients showed a reduction in 90-day mortality post-hospital discharge (average treatment effect [ATE]: -2.35%, 95% CI: -3.57, -1.13; p-value <0.001) compared to propensity-matched controls. We found a statistically significant reduction in 7-day hospital readmission by 2.15% (95% CI: -3.65, -0.65; p=0.005) and a nonsignificant reduction in 30-day readmission (ATE: -2.38%, 95% CI: -5.20, 0.45; p=0.099). There was a statistically significant increase in 30-day emergency department visits (ATE: 5.32%, 95% CI: 2.19, 8.46; 0.001) compared to matched controls. CONCLUSIONS: There was a reduction in 90-day all-cause mortality for the AMCS intervention group compared to matched controls, although the impact on hospital utilization was mixed. AMCS are systems interventions that are effective tools to improve patient health and reduce all-cause mortality.

Racial Diversity Among American Cardiologists: Implications for the Past, Present, and Future.

In the United States, race-based disparities in cardiovascular disease care have proven to be pervasive, deadly, and expensive. African American/Black, Hispanic/Latinx, and Native/Indigenous American individuals are at an increased risk of cardiovascular disease and are less likely to receive high-quality, evidence-based medical care as compared with their White American counterparts. Although the United States population is diverse, the cardiovascular workforce that provides its much-needed care lacks diversity. The available data show that care provided by physicians from racially diverse backgrounds is associated with better quality, both for minoritized patients and for majority patients. Not only is cardiovascular workforce diversity associated with improvements in health care quality, but racial diversity among academic teams and research scientists is linked with research quality. We outline documented barriers to achieving workforce diversity and suggest evidence-based strategies to overcome these barriers. Key strategies to enhance racial diversity in cardiology include improving recruitment and retention of racially diverse members of the cardiology workforce and focusing on cardiovascular health equity for patients. This review draws attention to academic institutions, but the implications should be considered relevant for nonacademic and community settings as well.

Trajectories of Opioid Use Following First Opioid Prescription in Opioid-Naive Youths and Young Adults.

Importance: Although prescription opioids are the most common way adolescents and young adults initiate opioid use, many studies examine population-level risks following the first opioid prescription. There is currently a lack of understanding regarding how patterns of opioid prescribing following the first opioid exposure may be associated with long-term risks. Objective: To identify distinct patterns of opioid prescribing following the first prescription using group-based trajectory modeling and examine the patient-, clinician-, and prescription-level factors that may be associated with trajectory membership during the first year. Design, Setting, and Participants: This cohort study examined Pennsylvania Medicaid enrollees' claims data from 2010 through 2016. Participants were aged 10 to 21 years at time of first opioid prescription. Data analysis was performed in March 2020. Main Outcomes and Measures: This study used group-based trajectory modeling and defined trajectory status by opioid fill. Results: Among the 189 477 youths who received an initial opioid prescription, 107 562 were female (56.8%), 81 915 were non-Latinx White (59.6%), and the median age was 16.9 (interquartile range [IQR], 14.6-18.8) years. During the subsequent year, 47 477 (25.1%) received at least one additional prescription. Among the models considered, the 2-group trajectory model had the best fit. Of those in the high-risk trajectory, 65.3% (n = 901) filled opioid prescriptions at month 12, in contrast to 13.1% (n = 6031) in the low-risk trajectory. Median age among the high-risk trajectory was 19.0 years (IQR, 17.1-20.0 years) compared with the low-risk trajectory (17.8 years [IQR, 15.8-19.4 years]). The high-risk trajectory received more potent prescriptions compared with the low-risk trajectory (median dosage of the index month for high-risk trajectory group: 10.0 MME/d [IQR, 5.0-21.2 MME/d] vs the low-risk trajectory group: 4.7 MME/d [IQR, 2.5-7.8 MME/d]; P < .001). The trajectories showed persistent differences with more youths in the high-risk trajectory going on to receive a diagnosis of opioid use disorder (30.0%; n = 412) compared with the low-risk group (10.1%; n = 4638) (P < .001). Conclusions and Relevance: This study's results identified 2 trajectories associated with elevated risk for persistent opioid receipt within 12 months following first opioid prescription. The high-risk trajectory was characterized by older age at time of first prescription, and longer and more potent first prescriptions. These findings suggest even short and low-dose opioid prescriptions can be associated with risks of persistent use for youths.

Implementation Science to Address Health Disparities During the Coronavirus Pandemic.

The coronavirus disease 2019 (COVID-19) pandemic is disproportionally affecting racial and ethnic minorities. In the United States, data show African American, Hispanic, and Native American populations are overrepresented among COVID-19 cases and deaths. As we speed through the discovery and translation of approaches to fight COVID-19, these disparities are likely to increase. Implementation science can help address disparities by guiding the equitable development and deployment of preventive interventions, testing, and, eventually, treatment and vaccines. In this study, we discuss three ways in which implementation science can inform these efforts: (1) quantify and understand disparities; (2) design equitable interventions; and (3) test, refine, and retest interventions.

Psychosocial and Clinical Risk Factors Associated with Substance Use in Observational Cohort of Patients with Sickle Cell Disease.

BACKGROUND: Patients with sickle cell disease (SCD) experience high rates of chronic pain, and have a high burden of mental health comorbidities shown to negatively influence health. There is limited research on substance use among individuals with SCD. Objective: The aim of this study is to measure the prevalence of substance use in patients with SCD and determine whether psychosocial or clinical risk factors are associated with substance use. Methods: This study was conducted as part of an observational study of patients with SCD at two academic medical centers. We asked participants (ages 15 and older) about the lifetime use of heroin, cocaine, amphetamines, and marijuana/cannabis. We measured stigma, depression, urban life stress, pain catastrophizing, and asked about a brief pain inventory. Results: Of 258 participants, 24.9% (n = 71) reported substance use. Marijuana was the most common substance used (22.5%; n = 65). The mean depressive score met criteria for positive screen amongst individuals who reported a history of substance use (mean 10.7(5.76)). Adjusting for age, sex, yearly family income, and education level, odds of substance use increased with higher levels of internalized stigma (aOR: 1.38; 95% CI: 1.07, 1.77; p = 0.012); higher urban life stress scores (aOR 1.06; 95% CI: 1.01, 1.12; p = 0.017) and higher pain catastrophizing scores (aOR: 1.03; 95% CI: 1.01, 1.06; p = 0.008). Conclusions: Among individuals with SCD who endorse substance use, there was markedly more stress and distress with higher rates of depression and poorer quality of life. Interventions focusing on improving distress tolerance and coping to not only pain, but also social stressors, might reduce substance use.

Marijuana use and health behaviors in a US clinic sample of patients with sickle cell disease.

INTRODUCTION: As marijuana use becomes more common, it is essential clinicians understand the relationship between marijuana use and health behaviors. METHODS: Using a retrospective cohort of adolescents and adults with sickle cell disease (SCD) stratified into a young (<25 years) and older cohort (> = 25 years), we conducted multiple linear regression examining relationship of marijuana use (independent variable) on each dependent variable (SCD self-management score and pain management). RESULTS: Among young cohort, 16.9% used marijuana compared to 21.8% of older cohort. The younger cohort reporting marijuana use had lower mean self-care scores (ß = -2.74;p = 0.009) and were more likely to have admissions to the hospital for pain (ß = 0.87;p = 0.047) compared to non-users. In contrast, the older cohort reporting marijuana use had more days treating pain at home (ß = 0.44;p = 0.035). CONCLUSIONS: Only a minority of patients with SCD reported lifetime marijuana use. Among those reporting marijuana use, there were different associations with self-care and health-related behaviors by age. The older cohort who endorsed marijuana use reported more days of treating pain at home, although this did not translate into increased acute care visits for pain crisis. Among youth, endorsing marijuana use was associated with worse SCD self-care.

Management of Opioid Misuse and Opioid Use Disorders Among Youth.

In response to the growing impact of the current opioid public health crisis in the United States on adolescents and young adults, pediatricians have an expanding role in identifying opioid use early, preventing escalation of risky use, reducing opioid-related harms, and delivering effective therapies. Research and expert consensus suggest the use of brief interventions focused on reducing risks associated with ongoing opioid use and using motivational interviewing strategies to engage youth in treatment. Because fatal opioid overdose remains a major cause of opioid-related mortality among youth, delivering overdose education as part of any visit in which a youth endorses opioid use is one evidence-based strategy to decrease the burden of opioid-related mortality. For youth that are injecting opioids, safe injection practices and linkage to needle or syringe exchanges should be considered to reduce complications from injection drug use. It is crucial that youth be offered treatment at the time of diagnosis of an opioid use disorder (OUD), including medications, behavioral interventions, and/or referral to mutual support groups. The 2 medications commonly used for office-based OUD treatment in adolescents are extended-release naltrexone (opioid antagonist) and buprenorphine (partial opioid agonist), although there is a significant treatment gap in prescribing these medications to youth, especially adolescents <18 years of age. Addiction is a pediatric disease that pediatricians and adolescent medicine physicians are uniquely poised to manage, given their expertise in longitudinal, preventive, and family- and patient-centered care. Growing evidence supports the need for integration of OUD treatment into primary care.

Feasibility of implementing mobile technology-delivered mental health treatment in routine adult sickle cell disease care.

Sickle cell disease (SCD) is a severe hemoglobinopathy characterized by acute and chronic pain. Sufferers of the disease, most of whom are underrepresented minorities, are at increased risk for mental health disorders. The purpose of this study is to test the acceptability and implementation of a computerized cognitive behavioral therapy (cCBT) intervention, Beating the Blues, to improve depression, anxiety, and pain in patients with SCD. Adults with SCD and significant symptoms of depression (Patient Health Questionnaire [PHQ-9] score ≥ 10) or anxiety (Generalized Anxiety Disorder Scale [GAD-7] score ≥ 10) were eligible to participate and be randomized to either receive eight sessions of cCBT with care coach support or treatment as usual. Participants reported daily pain and mood symptoms using a mobile diary app. Depression, anxiety, and pain symptoms were assessed at 1, 3, and 6 months. Thirty patients were enrolled: 18 to cCBT, and 12 to control. The cCBT intervention was feasible to implement in clinical settings and acceptable to participants. Patients in the cCBT arm reported a marginally greater decrease in depression at 6 months (-3.82, SE = 1.30) than those in the control group (-0.50, SE = 1.60; p = .06). There were no significant effects of treatment on anxiety; however, cCBT was associated with improved daily pain reported via a mobile diary app (p = .014). cCBT, delivered via mobile device, is a feasible strategy to provide mental health care to adults living with SCD. cCBT was acceptable to the target population; was able to be implemented in real-world, nonideal conditions; and has the potential to improve patient-reported outcomes.

Managing Opioids, Including Misuse and Addiction, in Patients With Serious Illness in Ambulatory Palliative Care: A Qualitative Study.

BACKGROUND: Pain and opioid management are core ambulatory palliative care skills. Existing literature on how to manage opioid misuse/use disorder excludes patients found in palliative care settings, such as individuals with serious illness or those at the end of life. OBJECTIVES: We conducted an exploratory study to: (1) Identify the challenges palliative care clinicians face when prescribing opioids in ambulatory settings and (2) explore factors that affect opioid decision-making. METHODS: We recruited palliative care clinicians who prescribe opioids in ambulatory settings, which included open-ended questions and was conducted online. Results were analyzed qualitatively using a content analysis-based approach. RESULTS: Eighty-three palliative care clinicians (mostly MDs/DOs) participated. Challenges faced when prescribing opioids included clinician differences in approach to care (eg, transitioning from another clinician with more permissive opioid prescribing), medication access (eg, inadequate pharmacy supply), resource constraints (eg, access to mental health and addiction expertise), managing problems outside the typical palliative care scope (eg addiction). Participants also discussed factors that influenced their opioid prescribing decisions, such as opioid-related harms and risks that they need to weigh; they also spoke about the necessity of considering other factors like the patient's environment, disease, treatment, and prognosis. CONCLUSION: This study highlights the challenge of opioid management in patients with serious illness, particularly when misuse or substance use disorder is present, and suggests areas for future research focus. Our next step will be to establish consensus on approaches to opioid prescribing decision-making and policy in seriously ill patients presenting to ambulatory palliative care.

Using Post-discharge Home Visitation to Improve Cultural Sensitivity and Patient-centered Discharge Planning by Internal Medicine Trainees.

BACKGROUND: Patient-centered discharge planning improves transitional care and health outcomes for vulnerable adults. The HOME Initiative was an educational intervention aiming to improve trainees' patient-centered discharge planning skills. METHODS: Using a quasi-experimental design, 52 internal medicine residents at an academic medical center were randomized to intervention or control in 2014-2015. Intervention interns visited recently discharged patients during inpatient rotations. Interns addressed patient deficits in understanding, rectified medication errors, and provided health education. RESULTS: Over three-quarters (77%) of intervention interns completed pre-and post-tests. Intervention interns reported significant improvements in patient-centered discharge planning skills and delivery of culturally sensitive care. Through improved communication skills, residents more effectively elicited patients' illness narratives and assessed their patients' safety (0.65; p=.05), functional status (0.79; p=.02) and health literacy (0.70; p=.01). CONCLUSION: Structured home visitation with recently discharged patients is a valuable tool for medical residents to learn patient-centered discharge planning and improve delivery of culturally sensitive care.