Use of Telehealth for Opioid Use Disorder Treatment in Safety Net Primary Care Settings: A Mixed-Methods Study.

Background: The COVID-19 pandemic resulted in a marked increase in telehealth for the provision of primary care-based opioid use disorder (OUD) treatment. This mixed methods study examines characteristics associated with having the majority of OUD-related visits via telehealth versus in-person, and changes in mode of delivery (in-person, telephone, video) over time. Methods: Logistic regression was performed using electronic health record data from patients with ≥1 visit with an OUD diagnosis to ≥1 of the two study clinics (Rural Health Clinic; urban Federally Qualified Health Center) and ≥1 OUD medication ordered from 3/8/2020-9/1/2021, with >50% of OUD visits via telehealth (vs. >50% in-person) as the dependent variable and patient characteristics as independent variables. Changes in visit type over time were also examined. Inductive coding was used to analyze data from interviews with clinical team members (n = 10) who provide OUD care to understand decision-making around visit type. Results: New patients (vs. returning; OR = 0.47;95%CI:0.27-0.83), those with ≥1 psychiatric diagnosis (vs. none; OR = 0.49,95%CI:0.29-0.82), and rural clinic patients (vs. urban; OR = 0.05; 95%CI:0.03-0.08) had lower odds of having the majority of visits via telehealth than in-person. Patterns of visit type varied over time by clinic, with the majority of telehealth visits delivered via telephone. Team members described flexibility for patients as a key telehealth benefit, but described in-person visits as more conducive to building rapport with new patients and those with increased psychological burden. Conclusion: Understanding how and why telehealth is used for OUD treatment is critical for ensuring access to care and informing OUD-related policy decisions.

Improving Management of Opioid Use Disorder Training With Novel Resident Co-PCP Model.

Introduction: Multiple organizations have recommended primary care physicians (PCP) implement medication for opioid use disorder (MOUD) programs to address the opioid epidemic, but that has been hindered by residency graduates feeling unprepared to provide these services. This study describes a program innovation to increase exposure to MOUD in residents' own continuity practices. Methods: We designed, reviewed, and implemented a co-PCP model to increase resident MOUD visits at one rural health clinic in the Pacific Northwest that is part of a large academic health center. We then measured resident MOUD panels before and after to assess success of this novel program. Results: After implementation of the novel co-PCP model, the number of residents having at least three MOUD patients increased from two (25%) to eight (100%) over 8 months. Conclusions: The novel co-PCP model of care effectively increased exposure to MOUD care in one resident continuity practice. This may be a successful practice change for improving resident preparation to provide MOUD care after graduation and to expand access to these services for further progress on the opioid epidemic.

Associations of retention on buprenorphine for opioid use disorder with patient characteristics and models of care in the primary care setting.

INTRODUCTION: Buprenorphine, a medication for opioid use disorder (OUD), can be administered within primary care; however, little is known about characteristics associated with retention on buprenorphine in these settings. This study examines patient correlates of buprenorphine retention and whether an integrated, interdisciplinary treatment model (buprenorphine and behavioral health) is associated with higher odds of buprenorphine retention than a primarily medication-only treatment model. METHODS: Electronic health record data from adult patients with an OUD, ≥1 buprenorphine order and ≥1 visit to either of two primary care clinics between 9/2/2014-6/27/2018 were extracted (N = 494 patients). Two research team members reviewed the medication start and stop dates for each buprenorphine order and classified as retained (≥6 months of orders) or not retained (<6 months of orders). Logistic regressions estimated the odds of retention on buprenorphine by 1) patient characteristics and 2) timing of patient's engagement in buprenorphine treatment (pre- or post-implementation of an integrated treatment model). RESULTS: Of the study sample, 53% had ≥6 months of buprenorphine orders. Almost two times higher odds of retention were found among patients with ≥1 psychiatric comorbidity (versus none) and among those with buprenorphine orders in the post- versus pre-period. CONCLUSIONS: An integrated, interdisciplinary model of OUD treatment was associated with ≥6 months of buprenorphine orders among our study population. Continued research is needed in real-world primary care settings to understand the impact of OUD treatment models on patient outcomes. A more nuanced examination of the associations between psychiatric diagnoses and buprenorphine treatment retention is warranted.

Improving Hierarchical Condition Category Coding by Family Medicine Residents Using a Web-Based, Interactive Module.

BACKGROUND AND OBJECTIVES: The proper documentation of Hierarchical Condition Category (HCC) codes is essential for risk-adjusted reimbursement, chart accuracy, and clinical communication within primary care, but represents a significant training gap in resident education. Our goal was to improve the understanding and confidence level of family medicine residents with HCC coding during outpatient primary care visits. METHODS: We developed and distributed a web-based, interactive module to family medicine residents at our academic institution. We assessed module impact through pre- and postsurveys focusing on knowledge, confidence, and experience with HCC coding. RESULTS: Twenty-eight of 48 preeducation surveys were returned (response rate of 58%), including 16 junior (PGY-1-2) and 12 senior (PGY-3-4) residents. A majority of residents answered each HCC knowledge question correctly. Median baseline confidence with HCC coding for all respondents was 4 (interquartile range [IQR]: 2, 6; scale 0-10; 10=most confident): senior residents 6 (IQR: 5, 7) versus junior residents 2 (IQR: 2, 4). Forty-six percent of respondents noted some previous education on HCC codes, including 75% of senior vs 25% of junior residents. Twenty-six residents completed the educational module. Posttest surveys (n=5, response rate: 19%) demonstrated median confidence of 7 (IQR: 4, 8.5). CONCLUSIONS: Family medicine residents displayed a high degree of knowledge but low confidence with HCC coding. Posteducation surveys suggest the possibility of a positive impact of our e-module, though further intervention roll out and data collection are needed to evaluate this effect.

Predictors of Medication-Assisted Treatment Initiation for Opioid Use Disorder in an Interdisciplinary Primary Care Model.

INTRODUCTION: Medication-assisted treatment (MAT) for opioid use disorder (OUD) is underused in primary care. Little is known about patient demographics associated with MAT initiation, particularly among models with an interdisciplinary approach, including behavioral health integration. We hypothesize few disparities in MAT initiation by patient characteristics after implementing this model for OUD. METHODS: Electronic health record data were used to identify adults with ≥1 primary care visit in 1 of 2 study clinics in a Pacific Northwest academic health system between September 1, 2015 and August 31, 2017 (n = 23,372). Rates of documented OUD diagnosis were calculated. Multivariate logistic regression estimated odds ratios of MAT initiation, defined as ≥1 electronic health record order for buprenorphine or naltrexone, by patient covariates. RESULTS: Seven percent of the study sample had an OUD diagnosis. Of those patients, 32% had ≥1 MAT order. Patients with documented psychiatric diagnoses or tobacco use had higher odds of initiating MAT (odds ratio [OR] = 1.62, P = .0003; OR = 2.46, P < .0001, respectively). Uninsured, Medicaid, and Medicare patients had lower odds than those commercially insured (OR = 0.53, 0.38, and 0.31, respectively; P < .0001). Patients who were older, of a race/ethnicity other than non-Hispanic white, had documented diabetes, and had documented asthma or chronic obstructive pulmonary disease showed lower odds of initiation. DISCUSSION: MAT initiation varied by patient characteristics, including disparities by insurance coverage and race/ethnicity. The addition of behavioral health did not eliminate disparities in care, but higher odds of initiation among those with a documented psychiatric diagnosis may suggest this model reaches some vulnerable populations. Additional research is needed to further examine these findings.

To Really Know the Disease: Creating a Participatory Community Education Workshop about Taenia solium Focused on Physical, Economic, and Epidemiologic Evidence.

Cysticercosis, caused by Taenia solium, is a neglected disease that causes preventable epilepsy. We conducted an experiential learning workshop in northern Peru to educate community members on T. solium transmission and motivate participation in community-led prevention and control. The workshop included presentation of local economic and epidemiologic data, followed by hands-on participation in pig dissection, group discussion of the T. solium life cycle, and viewing of eggs and nascent tapeworms with light microscopes. Among heads of household, we used community survey data to compare knowledge of the three-stage parasite life cycle at baseline and 2 months postworkshop. Knowledge of the life cycle increased significantly after the workshop, with greater gains for workshop attendees than non-attendees. Prior knowledge and workshop attendance were significant predictors of postworkshop knowledge. The use of local evidence and experiential learning positively affected knowledge of T. solium transmission, laying the foundation for subsequent community-engaged control efforts.

Evaluating Urban Taeniasis as a Threat to Cysticercosis Elimination in Northern Peru.

Reintroduction of Taenia solium into a region in Peru where it had been eliminated prompted evaluation of the possibility of reintroduction from an urban reservoir of taeniasis. In a cross-sectional study of an adjacent urban area, we found low prevalence of taeniasis (4/1,621; 0.25%), suggesting minimal risk of parasite reintroduction into rural areas through this route.

The evolution of morality and its rollback.

According to most Evolutionary Psychologists, human moral attitudes are rooted in cognitive modules that evolved in the Stone Age to solve problems of social interaction. A crucial component of their view is that such cognitive modules remain unchanged since the Stone Age, and I question that here. I appeal to evolutionary rollback, the phenomenon where an organ becomes non-functional and eventually atrophies or disappears-e.g. cave-dwelling fish losing their eyes. I argue that even if cognitive modules evolved in the Stone Age to solve problems of social interaction, conditions since then have favoured rollback of those modules. This is because there are institutions that solve those problems-e.g. legal systems. Moreover, evidence suggests that where external resources are available to perform cognitive tasks, humans often use them instead of internal ones. In arguing that Stone Age cognitive modules are unchanged, Evolutionary Psychologists say that evolutionary change is necessarily slow, and that there is high genetic similarity between human populations worldwide. I counter-argue that what is necessarily slow is the building-up of complex mechanisms. Undoing this can be much quicker. Moreover, rollback of cognitive mechanisms need not require any genetic change. Finally, I argue that cross-cultural similarity in some trait need not be rooted in genetic similarity. This is not intended as decisive evidence that rollback has occurred. To finish, I suggest ways we might decide whether moral attitudes are likely to be rooted in unchanged Stone Age modules, given that I have argued that cross-cultural similarity is not enough.

Neurocysticercosis among People Living Near Pigs Heavily Infected with Cysticercosis in Rural Endemic Peru.

Neurocysticercosis causes substantial neurologic morbidity in endemic regions around the world. In this cross-sectional study, we describe the frequency of neurocysticercosis among a presumed high-risk group of people in an endemic community in northern Peru. Participants who screened positive on a nine-question seizure survey were evaluated clinically to diagnose epilepsy using International League Against Epilepsy criteria. Those with epilepsy were offered a noncontrast computerized tomography (CT) of the head. We also tested sera from all participants using the lentil lectin-bound glycoprotein enzyme-linked immunoelectrotransfer blot (EITB) to detect anti-cysticercus antibodies and enzyme-linked immunosorbent assay (ELISA) B60/B158 to detect cysticercosis antigens. Participants with strongly positive ELISA (ratio ≥ 3) were offered a noncontrast magnetic resonance imaging (MRI) of the brain. We diagnosed 16 cases of epilepsy among 527 people screened (lifetime prevalence 30 per 1,000). Twelve with epilepsy accepted CT scan and five (41.7%) had parenchymal calcifications. None had viable cysts. Of the 514 who provided a blood sample, 241 (46.9%) were seropositive by EITB and 12 (2.9%) were strongly positive by ELISA (ratio ≥ 3). Eleven accepted MRI and eight (72.3%) had neurocysticercosis, including five with extraparenchymal cysts, five with parenchymal vesicular cysts, and two with parenchymal granulomas. These findings show that clinically relevant forms of neurocysticercosis and epilepsy can be found by applying screening interventions in communities endemic to Taenia solium. Longitudinal controlled studies are needed to better understand which subgroups are at highest risk and which are most likely to have improved prognosis as a result of screening.

Clinical value of prostate segmentation and volume determination on MRI in benign prostatic hyperplasia.

Benign prostatic hyperplasia (BPH) is a nonmalignant pathological enlargement of the prostate, which occurs primarily in the transitional zone. BPH is highly prevalent and is a major cause of lower urinary tract symptoms in aging males, although there is no direct relationship between prostate volume and symptom severity. The progression of BPH can be quantified by measuring the volumes of the whole prostate and its zones, based on image segmentation on magnetic resonance imaging. Prostate volume determination via segmentation is a useful measure for patients undergoing therapy for BPH. However, prostate segmentation is not widely used due to the excessive time required for even experts to manually map the margins of the prostate. Here, we review and compare new methods of prostate volume segmentation using both manual and automated methods, including the ellipsoid formula, manual planimetry, and semiautomated and fully automated segmentation approaches. We highlight the utility of prostate segmentation in the clinical context of assessing BPH.

Fully automated prostate segmentation on MRI: comparison with manual segmentation methods and specimen volumes.

OBJECTIVE: The objective of our study was to compare calculated prostate volumes derived from tridimensional MR measurements (ellipsoid formula), manual segmentation, and a fully automated segmentation system as validated by actual prostatectomy specimens. MATERIALS AND METHODS: Ninety-eight consecutive patients (median age, 60.6 years; median prostate-specific antigen [PSA] value, 6.85 ng/mL) underwent triplane T2-weighted MRI on a 3-T magnet with an endorectal coil while undergoing diagnostic workup for prostate cancer. Prostate volume estimates were determined using the formula for ellipsoid volume based on tridimensional measurements, manual segmentation of triplane MRI, and automated segmentation based on normalized gradient fields cross-correlation and graph-search refinement. Estimates of prostate volume based on ellipsoid volume, manual segmentation, and automated segmentation were compared with prostatectomy specimen volumes. Prostate volume estimates were compared using the Pearson correlation coefficient and linear regression analysis. The Dice similarity coefficient was used to quantify spatial agreement between manual segmentation and automated segmentation. RESULTS: The Pearson correlation coefficient revealed strong positive correlation between prostatectomy specimen volume and prostate volume estimates derived from manual segmentation (R = 0.89-0.91, p < 0.0001) and automated segmentation (R = 0.88-0.91, p < 0.0001). No difference was observed between manual segmentation and automated segmentation. Mean partial and full Dice similarity coefficients of 0.92 and 0.89, respectively, were achieved for axial automated segmentation. CONCLUSION: Prostate volume estimates obtained with a fully automated 3D segmentation tool based on normalized gradient fields cross-correlation and graph-search refinement can yield highly accurate prostate volume estimates in a clinically relevant time of 10 seconds. This tool will assist in developing a broad range of applications including routine prostate volume estimations, image registration, biopsy guidance, and decision support systems.

Videotaped patient stories: impact on medical students' attitudes regarding healthcare for the uninsured and underinsured.

The attitudes of medical students toward the current United States healthcare system are not well described in the literature. A graded survey was developed to assess awareness and motivation toward the care of the uninsured and underinsured as well as the impact of a video intervention on these attitudes. The survey, which showed good internal consistency (Cronbach's alpha = 0.85), was administered before and after viewing a collection of videotaped patient stories. Although a spectrum of beliefs emerged from the analysis of survey responses, some common attitudes were identified. Eighty-five percent of respondents either agreed or strongly agreed that medical care should be provided to everyone, regardless of their ability to pay. In addition, 66% indicated they would be willing to forgo a portion of their income to provide care to those who do not have access to healthcare services. These values were strongly correlated with increasing respondent age and primary care specialty choice (p<0.01). The video intervention did not heavily influence student responses, perhaps due to a ceiling effect created by the large number of students who were already sympathetic toward the underserved. Overall, this data reflects that United States medical students recognize a need to provide care to the underserved and are willing to make personal sacrifices to meet that need.