The association between opioid use disorder and skilled nursing facility acceptances: A multicenter retrospective cohort study.

BACKGROUND: Prior single-hospital studies have documented barriers to acceptance that hospitalized patients with opioid use disorder (OUD) face when referred to skilled nursing facilities (SNFs). OBJECTIVE: To examine the impact of OUD on the number of SNF referrals and the proportion of referrals accepted. DESIGN, SETTINGS, AND PARTICIPANTS: A retrospective cohort study of hospitalizations with SNF referrals in 2019 at two academic hospitals in Baltimore, MD. EXPOSURE: OUD status was determined by receipt of medications for OUD during admission, upon discharge, or the presence of a diagnosis code for OUD. KEY RESULTS: The cohort included 6043 hospitalizations (5440 hospitalizations of patients without OUD and 603 hospitalizations of patients with OUD). Hospitalizations of patients with OUD had more SNF referrals sent (8.9 vs. 5.6, p < .001), had a lower proportion of SNF referrals accepted (31.3% vs. 46.9%, p < .001), and were less likely to be discharged to an SNF (65.6% vs. 70.3%, p = .003). The effect of OUD status on the number of SNF referrals and the proportion of referrals accepted remained significant in multivariable analyses. Our subanalysis showed that reduced acceptances were driven by the hospitalizations of patients discharged without medications for OUD and those receiving methadone. Hospitalizations of patients discharged on buprenorphine were accepted at the same rates as hospitalizations of patients without OUD. CONCLUSIONS: This multicenter retrospective cohort study found that hospitalizations of patients with OUD had more SNF referrals sent and fewer referrals accepted. Further work is needed to address the limited discharge options for patients with OUD.

Evaluation of opioid use disorder treatment outcomes in patients receiving split daily versus once daily dosing of buprenorphine-naloxone.

INTRODUCTION: In clinical practice, sublingual (SL) buprenorphine-naloxone is prescribed as once daily or split daily dosing for the management of opioid use disorder (OUD). Evidence is lacking that assesses how split daily buprenorphine-naloxone affects OUD outcomes. This study aims to evaluate how the dosing frequency of SL buprenorphine-naloxone impacts therapy effectiveness when treating patients with OUD. METHODS: This retrospective analysis included adult outpatients prescribed treatment with SL buprenorphine-naloxone for OUD between July 1, 2016, and March 1, 2020. The study excluded patients with sickle cell disease, recent methadone treatment, or pregnancy. We characterized study groups by dosing frequency, either once daily or split dosing. The study compared retention in treatment, medication adherence, adherence to treatment program, and hospital encounters between groups. RESULTS: The study screened eight-hundred and seven patients, and included 250 patients newly prescribed SL buprenorphine-naloxone. Fifty-seven patients (22.8 %) were prescribed once daily dosing and 193 patients (77.2 %) were prescribed split daily dosing. The study found no significant differences noted in 12-month rates of treatment retention (52.6 % vs. 45.6 %, p = .35). These outcomes remained similar when assessed at three and six months. Within a year of buprenorphine-naloxone initiation, the study found no differences in the percentage of patients with hospitalizations (26.3 % vs. 38.3 %, p = .10), median number of hospitalizations (2 vs. 2), or proportion of days covered by a prescription ≥80 % (93.3 % vs. 92.0 %, p = .82). CONCLUSIONS: In this study, patients receiving once daily buprenorphine-naloxone had similar treatment outcomes to patients receiving split dosing. Further controlled studies are necessary to evaluate which patients are more likely to benefit from split dosing.

Use of intravenous buprenorphine microdosing to initiate medication for opioid use disorder in a patient with co-occurring pain: case report.

INTRODUCTION: Buprenorphine is used to treat opioid use disorder (OUD). However, therapy is often disrupted during acute pain episodes, and re-initiation is often deferred due to intolerable interruption in opioid analgesics. This case report describes a unique strategy for inducing buprenorphine without stopping opioid analgesics. CASE: One patient with OUD and acute pain was initiated on buprenorphine using intravenous microdosing without precipitated withdrawal or pain exacerbation. Full agonist opioids were successfully weaned after discharge and the patient was linked with a community-based treatment program. CONCLUSION: This case describes use of intravenous buprenorphine to treat OUD and acute pain without adverse consequences.

Family planning needs of young adults with sickle cell disease.

Sexual and reproductive healthcare standards for adolescents and young adults with sickle cell disease (SCD) are not established. A total of 50 young adults entering adult SCD care completed a Family Planning Survey assessing sexual and reproductive health needs from March 2019 to July 2020. Clinical data were abstracted from respondents' electronic medical records. Linear and logistic regression was applied to explore associations between clinical characteristics and survey results. Few respondents (8%) wished to be pregnant in the coming year, and 46% answered yes to at least one of four needs assessment questions. Those who were not employed full time were more likely to endorse needing help with getting sickle cell trait testing for a partner (ORadj = 9.59, p-value = 0.05). Contraceptive use was associated with having an obstetrician-gynecologist (OR = 6.8, p-value = 0.01). Young adults with SCD entering adult care have diverse reproductive health needs, highlighting opportunities to provide multidisciplinary, SCD-specific reproductive healthcare.

A Case for Comprehensive Transitional Care for Formerly Incarcerated Individuals.

People released from prison are at risk of adverse health outcomes in the weeks after release. This article describes cases that illustrate the complexity of caring for this population. It is important to address medical and psychological needs as well as factors that contribute to social determinants of health.

Development of an intravenous low-dose buprenorphine initiation protocol.

BACKGROUND: Buprenorphine is a life-saving treatment for opioid use disorder (OUD). Low-dose initiation (LDI) is an emerging buprenorphine initiation strategy that circumvents barriers associated with standard initiation. This study aims to describe tolerability and completion of LDI using intravenous (IV) buprenorphine and to define dosing protocols in a cohort of patients hospitalized in an urban academic hospital. METHODS: Data was collected via retrospective chart review for IV buprenorphine LDI cases initiated between September 1, 2020 and February 28, 2021. Cases were excluded if diagnostic criteria for OUD was not met, Clinical Opiate Withdrawal Scale (COWS) scores were not recorded, or sublingual (SL) buprenorphine was given within 24 h before IV buprenorphine. Completion of LDI and COWS data were assessed for all cases. Cases were categorized based on adherence to a dosing strategy and LDI indication, including OUD and acute pain, non-prescribed fentanyl exposure, and transition from methadone. RESULTS: Seventy-two cases were identified, and thirteen cases were excluded, leaving 59 cases in the population. Of these cases, 72.9% (43/59) tolerated LDI, and 91.5% (54/59) completed buprenorphine initiation. Forty-four (44/59, 75%) cases were adherent. Median duration of LDI within the adherent group was 23.7 h (IQR 22.8-27.0), 37.1 h (IQR 36.2-40.9), and 48.8 h (IQR 47.0-52.4) for the "rapid," "moderate," and "slow" dosing strategies, respectively. CONCLUSIONS: IV buprenorphine LDI was tolerated and completed in a majority of patients. Dosing protocols allowed for rapid transition to sublingual buprenorphine. Acute pain or recent methadone or fentanyl exposure may inform IV LDI dosing strategy selection.

Review of the published literature to characterise clinical excellence in COVID-19 care.

COVID-19 continues to be a major source of global morbidity and mortality. It abruptly stressed healthcare systems early in 2020 and the pressures continue. Devastating hardships have been endured by individuals, families and communities; the losses will be felt for years to come. As healthcare professionals and organisations stepped up to respond to the overwhelming number of cases, it is understandable that the focus has been primarily on coping with the quantity of the demand. During a pandemic, it is not surprising that few papers have drawn attention to the quality of the care delivered to those afflicted with illness. Despite the challenges, clinicians caring for patients with COVID-19 have risen to the occasion. This manuscript highlights aspirational examples from the published literature of thoughtful and superb care of patients with COVID-19 using an established framework for clinical excellence (formulated by the Miller-Coulson Academy of Clinical Excellence).

The Paradox of Readmission Prevention Interventions: Missing Those Most in Need.

BACKGROUND: Post-hospitalization transition interventions remain a priority in preventing rehospitalization. However, not all patients referred for readmission prevention interventions receive them. We sought to 1) define patient characteristics associated with non-receipt of readmission prevention interventions (among those eligible for them), and 2) determine whether these same patient characteristics are associated with hospital readmission at the state level. METHODS: We used state-wide data from the Maryland Health Services Cost Review Commission to determine patient-level factors associated with state-wide readmissions. Concurrently, we conducted a retrospective analysis of discharged patients referred to receive 1 of 3 post-discharge interventions between January 2013 and July 2019-a nurse transition guide, post-discharge phone call, or follow-up appointment in our post-discharge clinic-to determine patient-level factors associated with not receiving the intervention. Multivariable generalized estimating equation logistic regression models were used to calculate the odds of not accepting or not receiving the interventions. RESULTS: Older age, male gender, black race, higher expected readmission rate, and lower socioeconomic status were significantly associated with 30-day readmission in hospitalized Maryland patients. Most of these variables (age, sex, race, payer type [Medicaid or non-Medicaid], and socioeconomic status) were also associated with non-receipt of intervention. CONCLUSIONS: We found that many of the same patient-level characteristics associated with the highest readmission risk are also associated with non-receipt of readmission reduction interventions. This highlights the paradox that patients at high risk of readmission are least likely to accept or receive interventions for preventing readmission. Identifying strategies to engage hard-to-reach high-risk patients continues to be an unmet challenge in readmission prevention.

Examining black and white racial disparities in emergency department consultations by age and gender.

BACKGROUND: While significant racial inequities in health outcomes exist in the United States, these inequities may also exist in healthcare processes, including the Emergency Department (ED). Additionally, gender has emerged in assessing racial healthcare disparity research. This study seeks to determine the association between race and the number and type of ED consultations given to patients presenting at a safety-net, academic hospital, which includes a level-one trauma center. METHOD: Retrospective data was collected on the first 2000 patients who arrived at the ED from 1/1/2015-1/7/2015, with 532 patients being excluded. Of the eligible patients, 77% (74.6% adults and 80.7% pediatric patients) were black and 23% (25.4% adults and 19.3% pediatric patients) were white. RESULTS: White and black adult patients receive similar numbers of ED consultations and remained after gender stratification. White pediatric males have a 91% higher incidence of receiving an ED consultation in comparison to their white counterparts. No difference was found between black and white adult patients when assessing the risk of receiving consultations. White adult females have a 260% higher risk of receiving both types of consultations than their black counterparts. Black and white pediatric patients had the same risk of receiving consultations, however, white pediatric males have a 194% higher risk of receiving a specialty consultation as compared to their white counterparts. DISCUSSION: Future work should focus on both healthcare practice improvements, as well as explanatory and preventive research practices. Healthcare practice improvements can encompass development of appropriate racial bias trainings and institutionalization of conversations about race in medicine.

Measuring the contribution of clinical rotations to skills confidence in primary care nurse practitioner students.

ABSTRACT: Primary care providers (PCPs) are essential components of a health care system, but there are shortages of PCPs. Nurse practitioners (NPs) are essential in meeting the needs of an increased demand for primary care, but there is a wide variety in the training offered to NP students. The purpose of this analysis is to determine student self-reported comfort in a variety of care delivery, covering primary care topics, including knowledge and skills. We conducted a preclinical and postclinical survey. Surveys were obtained before and at the conclusion of two clinical rotations in Baltimore, MD. Students were a part of a Health Resources and Services Administration-funded program to prepare NP students to practice in urban, underserved settings. Seventeen NP students NP students responded to both our pre- and postsurveys. Overall, student comfort increased in many focus areas, but no change was seen in important domains, including interpreting imaging studies, filling out common forms, and interpreting certain diagnostic tests. Further study of student skills and confidence at the conclusion of their study would be beneficial in determining if these gaps persist at entry into NP practice. Given wide variation in NP student training programs, it would be additionally beneficial to understand how these differences impact student skills and confidence during their clinical rotations and on entry to practice. Well rounded, broad-based education is necessary for the development of highly trained PCPs; greater understanding of student confidence, knowledge, and skills can assist educators in assuring that all NPs enter practice as safe and competent providers.

Adapting Interdisciplinary Transitional Ambulatory Practice to Meet the Challenges of COVID-19.

COVID-19 restructured the health care delivery process, catapulting telemedicine to the mainstream. The Johns Hopkins After Care Clinic (JHACC) continued transprofessional health care delivery in the telemedicine space by shifting to remote, asynchronous collaboration and a triage system. In 1 month after starting telemedicine, the JHACC had 907 encounters for 376 unique patients. Most patients reported satisfaction with their visits. Telemedicine lengthened visit completion times. Providers encountered many failed call attempts and limited access to videoconferencing. Barriers to sustainable interprofessional telemedicine include poor social determinants of health, limited reimbursement for nonphysician health professionals, and increased clinical and administrative time.

Hepatomegaly and short stature in a 14-year-old with type 1 diabetes mellitus: case report.

BACKGROUND: Mauriac syndrome is a rare consequence of poorly controlled insulin-dependent diabetes, characterized by hepatomegaly, growth failure, delayed onset of puberty, and cushingoid features. Case reports of patients with Mauriac syndrome are found infrequently in the literature given historic improvements in diabetes management due to readily available insulin therapy. METHODS: We describe a case of a 14-year-old girl who presented with acute onset abdominal pain, distention, and orthopnea. RESULTS: She had a history of poorly controlled insulin-dependent diabetes as well as short stature. Abdominal imaging revealed impressive hepatomegaly. Laboratory testing showed markedly elevated triglycerides and cholesterol. Mauriac syndrome was suspected and diagnosed by liver biopsy, which demonstrated significant glycogenic hepatopathy. CONCLUSIONS: This case provides an illustrative example of Mauriac syndrome in a child who did not experience delayed onset of puberty and continued to have regular menses unlike what has been previously described. Furthermore, this case highlights the important consideration for significant dyslipidemia in patients with Mauriac syndrome and discusses the challenges of controlling insulin-dependent diabetes in the adolescent population.

Building access to care in adult sickle cell disease: defining models of care, essential components, and economic aspects.

Sickle cell disease (SCD) is the most common inherited blood disorder in the United States. It is a medically and socially complex, multisystem illness that affects individuals throughout the lifespan. Given improvements in care, most children with SCD survive into adulthood. However, access to adult sickle cell care is poor in many parts of the United States, resulting in increased acute care utilization, disjointed care delivery, and early mortality for patients. A dearth of nonmalignant hematology providers, the lack of a national SCD registry, and the absence of a centralized infrastructure to facilitate comparative quality assessment compounds these issues. As part of a workshop designed to train health care professionals in the skills necessary to establish clinical centers focused on the management of adults living with SCD, we defined an SCD center, elucidated required elements of a comprehensive adult SCD center, and discussed different models of care. There are also important economic impacts of these centers at an institutional and health system level. As more clinicians are trained in providing adult-focused SCD care, center designation will enhance the ability to undertake quality improvement and compare outcomes between SCD centers. Activities will include an assessment of the clinical effectiveness of expanded access to care, the implementation of SCD guidelines, and the efficacy of newly approved targeted medications. Details of this effort are provided.

Unintentional use of fentanyl attributed to surreptitious cannabis adulteration.

OBJECTIVE: This case addresses the issue of surreptitious adulteration of cannabis. Many with opioid and substance use disorders use cannabis while receiving office-based opioid treatment (OBOT), making it valuable to understand the rationale for its use. Further study of the effects that cannabis use has on OBOT success or failure is necessary. CASE SUMMARY: A 50-year-old man receiving OBOT continually tested positive in urine drug screenings (UDSs) for fentanyl, while abstaining from all opiates, but he endorsed smoking cannabis 2-3 times weekly as a self-reported headache reliever and a sleep aid. After changing the source from which he bought cannabis, his UDS became negative for fentanyl. He was maintained on a stable dose of buprenorphine with a consistent UDS after this intervention and was able to make many positive lifestyle changes as a result (i.e., maintaining a relationship with his girlfriend, continuing attendance at support groups, and pursuing employment opportunities). PRACTICE IMPLICATIONS: The consequences of cannabis use on OBOT success are highly variable and dependent on many factors. Although the concern regarding adulteration of cannabis exists, there is no systematic monitoring or reliable data on its frequency or the magnitude of its effect, which generates a demand for further research and exploration. Depending on state-specific regulations, patients may be able to obtain cannabis from reliable, regulated (nonadulterated) sources. However, providers must thoroughly consider the barriers to patients obtaining medicinal or legalized cannabis.

Otitis Media Module in the Pediatric Preclerkship Educational Exercises (PRECEDE) Curriculum.

Introduction: The Johns Hopkins Pediatrics Clerkship developed the PRECEDE (preclerkship educational exercises) curriculum with the primary goal of offering students formative instruction in essential pediatric clinical skills to prepare them for their clerkship. PRECEDE sessions occur at the beginning of each basic clerkship for new clinical clerkship students. The otitis media module is one in a series of modules presented in the curriculum and consists of a lecture and four short skills-development stations, each with a faculty facilitator. Methods: This 2-hour module began with a 1-hour didactic overview of otitis media. Medical students were divided into three groups. One group learned about writing prescriptions via two otitis media clinical vignettes. Another group explored visualization and diagnosis of otitis media via video. The last student group was subdivided and learned proper techniques for positioning and restraining pediatric patients during otoscopic exams and the psychomotor skills for performing otoscopic examinations, including pneumatic otoscopy. Student groups rotated through all four activity stations. Students were guided through discussion to develop interpretation, diagnostic, and treatment skills for acute otitis media. Results: Between 2010 and 2012, 254 third- and fourth-year medical students participated in this module. When asked to evaluate overall quality, 86% of learners rated the module as excellent, and 14% rated it as good. Discussion: By establishing these important skills, students may be better equipped to develop appropriate otitis media assessments, diagnoses, and care plans for patients and to use otitis media as a platform for broad education in other essential pediatric skills.

An Examination of Racial Disparities in Inpatient Consultations.

OBJECTIVE: To determine whether racial disparities occurred among specialty and allied health inpatient consultations for patients admitted to adult hospital services at an academic hospital. METHODS: A retrospective data analysis of the first 2000 patients, ages 18 years or older, admitted to an academic hospital. RESULTS: No regression model demonstrated any statistically significant relation between race and type of inpatient consultation received. No statistically significant difference in the number of inpatient consultations was found. CONCLUSIONS: Processes within the healthcare setting studied did not contribute to racial differences in consultation services. Our findings suggest that implicit racial bias may not be a factor when ordering consultations, but the findings are more likely affected by more appropriate factors such as the patient's age, length of stay, and complexity/severity of illness score.