Improving Access to Psychotherapy: Implications of Wit Versus United Behavioral Health.

This column summarizes the verdict in the federal class action known as Wit v United Behavioral Health (UBH)/Optum, highlighting the verdict's implications for increasing access to care, implementing the mental health parity law, and reducing health disparities. Achieving these results requires recognition of the verdict as more than simply a nice news story, but as a decision that actually offers individual clinicians, their professional organizations, as well as patients, families, and their consumer organizations, a powerful tool for implementing change if they take up the task of learning how to use it. The verdict applies to outpatient treatment, including psychotherapy, along with 2 other levels of care: intensive outpatient programs and residential treatment.

Emergency Department and Urgent Care Medical Malpractice Claims 2001-15.

INTRODUCTION: This study reviews malpractice, also called medical professional liability (MPL), claims involving adult patients cared for in emergency departments (ED) and urgent care settings. METHODS: We conducted a retrospective review of closed MPL claims of adults over 18 years, from the Medical Professional Liability Association's Data Sharing Project database from 2001-2015, identifying 6,779 closed claims. Data included the total amount, origin, top medical specialties named, chief medical factors, top medical conditions, severity of injury, resolution, average indemnity, and defense costs of closed claims. RESULTS: Of 6,779 closed claims, 65.9% were dropped, withdrawn, or dismissed. Another 22.8% of claims settled for an average indemnity of $297,709. Of the 515 (7.6%) cases that went to trial, juries returned verdicts for the defendant in 92.6% of cases (477/515). The remaining 7.4% of cases (38/515) were jury verdicts for the plaintiff, with an average indemnity of $816,909. The most common resulting medical condition cited in paid claims was cardiac or cardiorespiratory arrest (10.4%). Error in diagnosis was the most common chief medical error cited in closed claims. Death was the most common level of severity listed in closed (38.5%) and paid (42.8%) claims. Claims reporting major permanent injury had the highest paid-to-closed ratio, and those reporting grave injury had the highest average indemnity of $686,239. CONCLUSION: This retrospective review updates the body of knowledge surrounding medical professional liability and represents the most recent analysis of claims in emergency medicine. As the majority of emergency providers will be named in a MPL claim during their career, it is essential to have a better understanding of the most common factors resulting in MPL claims.

Understanding the impact of the SARS-COV-2 pandemic on hospitalized patients with substance use disorder.

BACKGROUND: The SARS-COV-2 pandemic rapidly shifted dynamics around hospitalization for many communities. This study aimed to evaluate how the pandemic altered the experience of healthcare, acute illness, and care transitions among hospitalized patients with substance use disorder (SUD). METHODS: We performed a qualitative study at an academic medical center in Portland, Oregon, in Spring 2020. We conducted semi-structured interviews, and conducted a thematic analysis, using an inductive approach, at a semantic level. RESULTS: We enrolled 27 participants, and identified four main themes: 1) shuttered community resources threatened patients' basic survival adaptations; 2) changes in outpatient care increased reliance on hospitals as safety nets; 3) hospital policy changes made staying in the hospital harder than usual; and, 4) care transitions out of the hospital were highly uncertain. DISCUSSION: Hospitalized adults with SUD were further marginalized during the SARS-COV-2 pandemic. Systems must address the needs of marginalized patients in future disruptive events.

The influence of a ban on outpatient intravenous antibiotic therapy among the secondary and tertiary hospitals in China.

BACKGROUND: Antimicrobial resistance (AMR) is a serious global public health challenge. Physicians' over-prescription of antibiotics is a major contributor, and intravenous (IV) antibiotic use has been a particular concern in China. To address the rapid fallout of antibiotic overuse, the Chinese government has piloted a ban of IV antibiotics in the outpatient department (OD) with the exemption of paediatrics, emergency department (ED), and inpatient ward of secondary and tertiary hospitals in several provinces. METHODS: To assess the potential impact of the policy, we conducted a mixed-methods study including 1) interviews about the ban of IV antibiotic use with 68 stakeholders, covering patients, health workers, and policy-makers, from two cities and 2) a hospital case study which collected routine hospital data and survey data with 207 doctors. RESULTS: Our analyses revealed that the ban of IV antibiotics in the OD led to a reduction in the total and IV antibiotic prescriptions and improved the rational antibiotic prescribing practice in the OD. Nevertheless, the policy has diverted patient flow from OD to ED, inpatient ward, and primary care for IV antibiotic prescriptions. We also found that irrational antibiotic use in paediatrics was neglected. Radical policy implementation, doctors circumvented the regulations, and lack of doctor-patient communication during patient encounters were barriers to the implementation of the ban. CONCLUSIONS: Future efforts may include 1) to de-escalate both oral and IV antibiotic therapy in paediatric and reduce oral antibiotic therapy among adults in outpatient clinics, 2) to reduce unnecessary referrals by OD doctors to ED, primary care, or inpatient services and better coordinate for patients who clinically need IV antibiotics, 3) to incorporate demand-side tailored measures, such as public education campaigns, and 4) to improve doctor-patient communication. Future research is needed to understand how primary care and other community clinics implement the ban.

State and federal abortion restrictions increase risk of COVID-19 exposure by mandating unnecessary clinic visits.

OBJECTIVE: To quantify the number of medically unnecessary clinical visits and in-clinic contacts monthly caused by US abortion regulations. STUDY DESIGN: We estimated the number of clinical visits and clinical contacts (any worker a patient may come into physical contact with during their visit) under the current policy landscape, compared to the number of visits and contacts if the following regulations were repealed: (1) State mandatory in-person counseling visit laws that necessitate two visits for abortion, (2) State mandatory-ultrasound laws, (3) State mandates requiring the prescribing clinician be present during mifepristone administration, (4) Federal Food and Drug Administration Risk Evaluation and Mitigation Strategy for mifepristone. If these laws were repealed, "no-test" telemedicine abortion would be possible for some patients. We modeled the number of visits averted if a minimum of 15 percent or a maximum of 70 percent of medication abortion patients had a "no-test" telemedicine abortion. RESULTS: We estimate that 12,742 in-person clinic visits (50,978 clinical contacts) would be averted each month if counseling visit laws alone were repealed, and 31,132 visits (142,910 clinical contacts) would be averted if all four policies were repealed and 70 percent of medication abortion patients received no-test telemedicine abortions. Over 2 million clinical contacts could be averted over the projected 18-month COVID-19 pandemic. CONCLUSION: Medically unnecessary abortion regulations result in a large number of excess clinical visits and contacts. POLICY IMPLICATIONS: Repeal of medically unnecessary state and federal abortion restrictions in the United States would allow for evidence-based telemedicine abortion care, thereby lowering risk of SARS-CoV-2 transmission.

Applying Collaborative Justice to Sexually Violent Predator Civil Commitment.

Sexually violent predator (SVP) statutes are unique in that these laws allow for the indefinite civil psychiatric commitment of sex offenders after their criminal sentences have been served. In addition to the high cost of psychiatric hospitalization, recently observed low base rates of sexual recidivism of sex offenders released from custody suggest that, in select SVP cases, a collaborative justice model of outpatient placement may be feasible in lieu of lengthy and costly placement in state hospitals. Given its position as one of the states with a large number of SVP commitments, California offers an opportunity to implement a collaborative justice model for adult sex offenders found to meet SVP criteria. In this article, a template for such a model is suggested. Admittedly, this model faces multiple obstacles, both within the judicial system and in the public arena. Nonetheless, public concerns may be mitigated through high-control parole plus additional treatment and controls, interim halfway house placement, and community prosocial support systems.

Antimicrobial stewardship in the primary care setting: from dream to reality?

BACKGROUND: Clinicians who work in primary care are potentially the most influential healthcare professionals to address the problem of antibiotic resistance because this is where most antibiotics are prescribed. Despite a number of evidence based interventions targeting the management of community infections, the inappropriate antibiotic prescribing rates remain high. DISCUSSION: The question is how can appropriate prescribing of antibiotics through the use of Antimicrobial Stewardship (AMS) programs be successfully implemented in primary care. We discuss that a top-down approach utilising a combination of strategies to ensure the sustainable implementation and uptake of AMS interventions in the community is necessary to support clinicians and ensure a robust implementation of AMS in primary care. Specifically, we recommend a national accreditation standard linked to the framework of Core Elements of Outpatient Antibiotic Stewardship, supported by resources to fund the implementation of AMS interventions that are connected to quality improvement initiatives. This article debates how this can be achieved. The paper highlights that in order to support the sustainable uptake of AMS programs in primary care, an approach similar to the hospital and post-acute care settings needs to be adopted, utilising a combination of behavioural and regulatory processes supported by sustainable funding. Without these strategies the problem of inappropriate antibiotic prescribing will not be adequately addressed in the community and the successful implementation and uptake of AMS programs will remain a dream.

The utility of outpatient civil commitment: Investigating the evidence.

BACKGROUND: Outpatient civil commitment (OCC), community treatment orders (CTOs) in European and Commonwealth nations, require the provision of needed-treatment to protect against imminent threats to health and safety. OCC-reviews aggregating all studies report inconsistent outcomes. This review, searches for consistency in OCC-outcomes by evaluating studies based on mental health system characteristics, measurement, and design principles. METHODS: All previously reviewed OCC-studies and more recent investigations were grouped by their outcome-measures' relationship to OCC statute objectives. A study's evidence-quality ranking was assessed. Hospital and service-utilization outcomes were grouped by whether they represented treatment provision, patient outcome, or the conflation of both. RESULTS: OCC-studies including direct health and safety outcomes found OCC associated with reduced mortality-risk, increased access to acute medical care, and reduced violence and victimization risks. Studies considering treatment-provision, found OCC associated with improved medication and service compliance. If coupled with assertive community treatment (ACT) or aggressive case management OCC was associated with enhanced ACT success in reducing hospitalization need. When outpatient-services were limited, OCC facilitated rapid return to hospital for needed-treatment and increased hospital utilization in the absence of a less restrictive alternative. OCC-studies measuring "total hospital days", "prevention of hospitalization", and "readmissions" report negative and/or no difference findings because they erroneously conflate their intervention (provision of needed treatment) and outcome. CONCLUSIONS: This investigation finds replicated beneficial associations between OCC and direct measures of imminent harm indicating reductions in threats to health and safety. It also finds support for OCC as a less restrictive alternative to inpatient care.

Experience from a Singapore tertiary hospital with restructuring of a vascular surgery practice in response to national and institutional policies during the COVID-19 pandemic.

Singapore was one of the first countries to be affected by COVID-19, with the index patient diagnosed on January 23, 2020. For 2 weeks in February, we had the highest number of COVID-19 cases behind China. In this article, we summarize the key national and institutional policies that were implemented in response to COVID-19. We also describe in detail, with relevant data, how our vascular surgery practice has changed because of these policies and COVID-19. We show that with a segregated team model, the vascular surgery unit can still function while reducing risk of cross-contamination. We explain the various strategies adopted to reduce outpatient and inpatient volume. We provide a detailed breakdown of the type of vascular surgical cases that were performed during the COVID-19 pandemic and compare it with preceding months. We discuss our operating room and personal protective equipment protocols in managing a COVID-19 patient and share how we continue surgical training amid the pandemic. We also discuss the challenges we might face in the future as COVID-19 regresses.

Psychiatrists' opinion about involuntary outpatient reatment.

INTRODUCTION: Involuntary outpatient treatment (IOT) is a kind of compulsory outpatient treatment, whose aim is to improve the adherence to the treatment in people with severe mental illness and with no awareness of disease. In these cases, therapeutic abandonment involves a high risk of relapse, with appearance of disruptive and/or self-aggressive or hetero-aggressive behavior, repeated hospitalizations and frequent emergencies. The application of IOT is not an issue without contention. Therefore, the need of legislative regulation in Spain has been a controversial subject for several years, and there are both advocates and opponents. OBJECTIVE: The objective of this study is to bring together the opinion of clinical psychiatrists and resident doctors in psychiatry on the involuntary outpatient treatment and its legislative regulation. MATERIAL AND METHOD: This study is descriptive in nature. The study population consists of 42 clinical professionals in mental health (32 psychiatrists and 10 resident doctors in psychiatry). At the beginning of this study (March 2018), some of these professionals were working in the Psychiatry Department's facilities of the University Hospital Complex of Huelva. A personal survey in paper form consisting of ten questions about IOT was carried out to each member of this study. RESULTS: 85.7% of clinicians know the current initiative that tries to carry out the legislative regulation of IOT, and 92.8% of them agree to such regulation. In this sense, 83.3% of them are against the fact that more coercive measures for the psychiatric patients such as the involuntary commitment or the civil incapacitation are regulated and IOT is not. On the one hand, 78.6% of the professionals in mental health believe that IOT is beneficial for the patients. Moreover, 95.2% of them think that is beneficial for their relatives, too. On the other hand, 78.6% of clinicians do not consider that the application of IOT to mentallyill patients is stigmatizing. CONCLUSION: The vast majority of clinicians think that the legislative regulation of involuntary outpatient treatment is necessary in Spain, and they think this treatment is beneficial not only for the patient but also for their family.

Emergency Radiology: An Underappreciated Source of Liability Risk.

PURPOSE: While several studies analyze radiology malpractice lawsuits, none specifically examines the site of service. The purpose of this study is to estimate the relative likelihood of a lawsuit arising from a radiology study performed in emergency (ED), inpatient (IP) and outpatient (OP) settings. METHODS: Referrals from a malpractice review consulting company over a six year period were compared to the 2016 Medicare Part B file and stratified by site of service. The proportion of exams for each site of service was estimated, and using absolute differences in proportions and odds ratios (ORs), differences in the place of service were calculated. RESULTS: The Cleareview cohort contained 25 (17%) IP, 56 (38%) OP, and 68 (46%) ED exams. In 2016, Medicare assigned benefits for 27,009,053 (20%) IP, 84,075,848 (62%) OP and 23,964,794 (18%) ED exams. The ORs (Cleareview: Medicare) of the ED to IP, OP, and IP+OP were 3.07 (95% CI: 1.56-6.03), 4.26 (95% CI: 2.76-6.59), 3.89 (95% CI: 2.60-5.83), respectively. By contrast, the OR for IP:OP between Cleareview and Medicare was not significantly different than 1 (OR: 1.39, 95% CI: 0.68-2.83, P = .38). DISCUSSION: Radiological studies performed in the ED accounted for a disproportionate number of liability claims against radiologists. Further study is warranted to confirm this finding with a more robust data set.

Outpatient Dialysis for Acute Kidney Injury: Progress and Pitfalls.

Dialysis-requiring acute kidney injury (AKI) has increased markedly in the United States. At the same time, mortality rates have recently improved. As such, increasing numbers of patients with AKI are surviving to hospital discharge, including up to 30% who will continue to require outpatient dialysis. In recent years, policy changes have significantly affected the care of this high-risk population. Beginning in 2017, new legislation reversed a previous Centers for Medicare & Medicaid Services policy that prohibited dialysis for AKI at end-stage renal disease (ESRD) facilities. This has improved dialysis options for patients, but the impact on patient outcomes remains uncertain. Unfortunately, there is currently a lack of evidence basis to guide management of this vulnerable patient population. Moving forward, additional data reporting and analyses will be required, analogous to how the US Renal Data System has helped inform ESRD care. As the dialysis setting for patients with AKI shifts to the ESRD setting, it is incumbent on the nephrology community to identify best practices to promote kidney recovery, recognizing that these practices will differ from standard ESRD protocols.

A Contemporary Medicolegal Analysis of Outpatient Interventional Pain Procedures: 2009-2016.

BACKGROUND: Closed malpractice claim studies allow a review of rare but often severe complications, yielding useful insight into improving patient safety and decreasing practitioner liability. METHODS: This retrospective observational study of pain medicine malpractice claims utilizes the Controlled Risk Insurance Company Comparative Benchmarking System database, which contains nearly 400,000 malpractice claims drawn from >400 academic and community medical centers. The Controlled Risk Insurance Company Comparative Benchmarking System database was queried for January 1, 2009 through December 31, 2016, for cases with pain medicine as the primary service. Cases involving outpatient interventional pain management were identified. Controlled Risk Insurance Company-coded data fields and the narrative summaries were reviewed by the study authors. RESULTS: A total of 126 closed claims were identified. Forty-one claims resulted in payments to the plaintiffs, with a median payment of $175,000 (range, $2600-$2,950,000). Lumbar interlaminar epidural steroid injections were the most common procedures associated with claims (n = 34), followed by cervical interlaminar epidural steroid injections (n = 31) and trigger point injections (n = 13). The most common alleged injuring events were an improper performance of a procedure (n = 38); alleged nonsterile technique (n = 17); unintentional dural puncture (n = 13); needle misdirected to the spinal cord (n = 11); and needle misdirected to the lung (n = 10). The most common alleged outcomes were worsening pain (n = 26); spinal cord infarct (n = 16); epidural hematoma (n = 9); soft-tissue infection (n = 9); postdural puncture headache (n = 9); and pneumothorax (n = 9). According to the Controlled Risk Insurance Company proprietary contributing factor system, perceived deficits in technical skill were present in 83% of claims. CONCLUSIONS: Epidural steroid injections are among the most commonly performed interventional pain procedures and, while a familiar procedure to pain management practitioners, may result in significant neurological injury. Trigger point injections, while generally considered safe, may result in pneumothorax or injury to other deep structures. Ultimately, the efforts to minimize practitioner liability and patient harm, like the claims themselves, will be multifactorial. Best outcomes will likely come from continued robust training in procedural skills, attention paid to published best practice recommendations, documentation that includes an inclusive consent discussion, and thoughtful patient selection. Limitations for this study are that closed claim data do not cover all complications that occur and skew toward more severe complications. In addition, the data from Controlled Risk Insurance Company Comparative Benchmarking System cannot be independently verified.

Referral and consultation process between family medicine and continuous medical attention / Proceso de interconsulta entre medicina familiar y atención médica continua

The process of sending patients between the outpatient service of family medicine and the continuous medical care service at the IMSS is well established in the various internal systems as well as in the applicable mexican official standards, but it is necessary for the personnel involved to know it well in order to avoid setbacks during the reference and counter-reference process within the unit.

El proceso de envío de pacientes entre el servicio de consulta externa de medicina familiar y el servicio de atención médica continua en el IMSS se encuentra bien establecido en los diversos ordenamientos internos así como en las normas oficiales mexicanas aplicables, pero es necesario que el personal involucrado lo conozca bien con el fin de evitar contratiempos durante el proceso de referencia-contrareferencia dentro de la unidad.

An Opinion Survey of Orthopaedic and Traumatology Surgeons Working in Outpatient Care (Society, Laws and Patients). / Eine Meinungsumfrage bei niedergelassenen Fachärzten für Orthopädie und Unfallchirurgie (Gesellschaft, Gesetz und Patienten).

BACKGROUND: The German health care system is well accepted, but efficiency, costs and patient satisfaction are sometimes criticised. Opinions and models prevail, and empirical data are rarely presented, although quantitative data are a precondition to assess the acceptance of the health care system. METHOD: To determine the appraisal of the patient-doctor relationship, economic situation and cooperation with clinical institutions, a 37 item was developed where participants indicated their agreement with a statement on a four point Likert scale. This questionnaire was answered by 525 German orthopaedic and/or traumatology surgeons, representing 7.7% of all German specialists working in outpatient care. RESULTS: 75% of all respondents felt challenged by demanding patients and a need for justification; what was less pronounced was the feeling of being exploited as physicians. Restrictions in medical treatment from budgeting expenses were seen by 74%. More than 90% considered that it was impossible to finance their medical practice expenses by conservative medical treatment only. The respondents felt similarly critical about the current cooperation with hospitals - only 19% were not interested in closer cooperation and 96% advocated higher fees for this cooperation. 74% confirmed that hospitals are taking over outpatient tasks, whereas only 35% agreed that more clinical patient care can be provided by outpatient providers, especially due to legal restrictions. DISCUSSION: Practitioning orthopaedic and traumatology surgeons feel exploited by uninformed patients, misallocation of reimbursement funds and legal restrictions, as well as unilateral substitution of outpatient care by hospitals. They do not consider that the current structures are sustainable for long term patient care.

The service-seeking profiles of youth reporting a legal mandate or perceived coercion for substance use treatment.

INTRODUCTION: There is paucity of research on treatment-related coercion in youth: most research focuses on adult populations and legally mandated treatment. This study aims to examine the service-seeking profiles of youth with substance misuse issues who report a legal mandate or perceived coercion to enter treatment. METHODS: Differences between youth who were legally mandated and not legally mandated, and differences between youth reporting high and low perceived coercion, were examined for demographic characteristics, mental health and substance use profiles, motivation, and readiness to change. RESULTS: Compared to participants reporting low perceived coercion, those experiencing high perceived coercion reported more substance use problems, greater mental health needs, and greater external and introjected motivation. Legally mandated youth reported fewer mental health issues, lower identified motivation, and greater readiness to change than those reporting no legal mandate. DISCUSSION: Many youth who present for substance use services report experiencing a sense of coercion, which suggests the potential importance of considering youth-centered strategies for involving youth in treatment planning and the development of treatment goals. Youth seeking treatment also have multiple intersecting needs which may benefit from a collaborative and integrative approach.

Do naloxone access laws increase outpatient naloxone prescriptions? Evidence from Medicaid.

BACKGROUND: Naloxone is a prescription medication that can quickly and effectively reverse opioid overdose. Medicaid is a major payer of substance use disorder services, and Medicaid beneficiaries experience especially high rates of opioid overdose. As opioid overdose rates have risen sharply, every state has modified its laws to make naloxone easier to access. The aim of this paper is to determine whether implementation of different provisions of naloxone access laws led to increased naloxone dispensing financed by Medicaid. METHODS: We reviewed naloxone legislation passed by every state between 2007 and 2016. We used the Medicaid State Drug Utilization dataset to examine the effect of different types of state naloxone access law provisions, separately and as a whole, on the number of outpatient naloxone prescriptions reimbursed by Medicaid from 2007 to 2016. We included state-level covariates in our models that may be correlated with naloxone utilization in Medicaid and passage of naloxone access laws. RESULTS: We found that the presence of any naloxone law was significantly associated with increases in outpatient naloxone reimbursed through Medicaid. Laws containing standing order provisions were most consistently associated with increases in naloxone dispensing across models. Standing order provisions led on average to an increase of approximately 33 naloxone prescriptions per state-quarter, which is equivalent to 74% of the average number of naloxone prescriptions per state-quarter. CONCLUSIONS: Naloxone access laws, particularly those with standing order provisions, appear to be an effective policy approach to increasing naloxone access among Medicaid beneficiaries.