Augmenting project ECHO for opioid use disorder with data-informed quality improvement.

BACKGROUND: National opioid-related overdose fatalities totaled 650,000 from 1999 to 2021. Some of the highest rates occurred in New Hampshire, where 40% of the population lives rurally. Medications for opioid use disorder (MOUD; methadone, buprenorphine, and naltrexone) have demonstrated effectiveness in reducing opioid overdose and mortality. Methadone access barriers disproportionally impact rural areas and naltrexone uptake has been limited. Buprenorphine availability has increased and relaxed regulations reduces barriers in general medical settings common in rural areas. Barriers to prescribing buprenorphine include lack of confidence, inadequate training, and lack of access to experts. To address these barriers, learning collaboratives have trained clinics on best-practice performance data collection to inform quality improvement (QI). This project sought to explore the feasibility of training clinics to collect performance data and initiate QI alongside clinics' participation in a Project ECHO virtual collaborative for buprenorphine providers. METHODS: Eighteen New Hampshire clinics participating in a Project ECHO were offered a supplemental project exploring the feasibility of performance data collection to inform QI targeting increased alignment with best practice. Feasibility was assessed descriptively, through each clinic's participation in training sessions, data collection, and QI initiatives. An end-of-project survey was conducted to understand clinic staff perceptions of how useful and acceptable they found the program. RESULTS: Five of the eighteen health care clinics that participated in the Project ECHO joined the training project, four of which served rural communities in New Hampshire. All five clinics met the criteria for engagement, as each clinic attended at least one training session, submitted at least one month of performance data, and completed at least one QI initiative. Survey results showed that while clinic staff perceived the training and data collection to be useful, there were several barriers to collecting the data, including lack of staff time, and difficulty standardizing documentation within the clinic electronic health record. CONCLUSIONS: Results suggest that training clinics to monitor their performance and base QI initiatives on data has potential to impact clinical best practice. While data collection was inconsistent, clinics completed several data-informed QI initiatives, indicating that smaller scale data collection might be more attainable.

Vitamin D deficiency in mycosis fungoides and Sézary syndrome patients is similar to other cancer patients.

BACKGROUND: The purpose of this study was to determine the prevalence of vitamin D deficiency in CTCL patients and whether supplementation corrects vitamin D deficiency or treatment outcome. PATIENTS AND METHODS: Three hundred eleven CTCL patients including 27/311 (8.7%) with Sézary syndrome (SS), 169 cancer controls, and 69 normal controls from the M.D. Anderson clinics had 25(OH)D3 levels determined and categorized as deficient (< 20 ng/mL),insufficient (20-29 ng/mL), or sufficient (≥ 30 ng/mL). Clinical response was determined according to a change in percent body surface area involvement. RESULTS: Low 25(OH)D3 (< 30 ng/mL) levels were present in 76.9% of mycosis fungoides/SS patients, 75.2% of cancer controls, and 66.7% of healthy controls (P » .05, .07) and in 30% to 39% of historical normal controls. Correction of deficiency was successful in 35% or 55 of 156 patients who were given dealer's choice of either vitamin D2 at 50,000 IU orally (p.o.) biweekly or D3 1000 IU p.o. daily. Correction of vitamin D levels was noted in 27 of 100 (27%) patients given D3 and 28 of 56 (50%) given D2. Responses to standard CTCL therapy was similar among patients with corrected and persistently low levels (P » .51). CONCLUSION: To our knowledge,this is the first study of vitamin D status in CTCL patients. Vitamin D deficiency was present in CTCL and other cancer patients compared with normal and historical controls. Correction of vitamin D deficiency and type of vitamin D supplementation used did not affect the overall clinical disease response.

Patient positioning (mobilisation) and bracing for pain relief and spinal stability in metastatic spinal cord compression in adults.

BACKGROUND: Many patients with metastatic spinal cord compression (MSCC) have spinal instability but are determined, by their clinician, to be unsuitable for surgical internal fixation due to their advanced disease. Mobilisation may be hazardous in the presence of spinal instability as further vertebral collapse can occur. Current guidance on positioning (or mobilisation) and spinal bracing is contradictory. OBJECTIVES: To investigate the correct positioning (or mobilisation) and examine the effects of spinal bracing to relieve pain or to prevent further vertebral collapse in patients with MSCC. SEARCH METHODS: The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, CANCERLIT, NICE, SIGN, AMED, TRIP, National Guideline Clearinghouse and PEDro database were searched; the last search was run in February 2012. SELECTION CRITERIA: We selected randomised controlled trials (RCTs) of adults with MSCC of interventions on positioning or mobilisation and bracing. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed each possible study for inclusion and quality. MAIN RESULTS: One thousand, six hundred and eleven potentially relevant studies were screened. No studies met the inclusion criteria. Many papers identified the importance of mobilisation but no RCTs have been undertaken. No RCTs of bracing in MSCC were identified. AUTHORS' CONCLUSIONS: There is lack of evidence based guidance around how to correctly position and when to mobilise patients with MSCC or if spinal bracing is an effective technique for reducing pain or improving quality of life. RCTs are required in this important area.