Rapid Access Addiction Medicine Clinics for People With Problematic Opioid Use.

Importance: New approaches are needed to provide care for individuals with problematic opioid use (POU). Rapid access addiction medicine (RAAM) clinics offer a flexible, low-barrier, rapid access care model for this population. Objective: To assess the associations of RAAM clinics with emergency department (ED) visits, hospitalizations, and mortality for people with POU. Design, Setting, and Participants: A retrospective cohort study involving a matched control group was performed using health administrative data from Ontario, Canada. Anonymized data from 4 Ontario RAAM clinics (cities of Ottawa, Toronto, Oshawa, and Sudbury) were linked with health administrative data. Analyses were performed on a cohort of individuals who received care at participating RAAM clinics and geographically matched controls who did not receive care at a RAAM clinic. All visits occurred between October 2, 2017, and October 30, 2019, and data analyses were completed in spring 2023. A propensity score-matching approach was used to balance confounding factors between groups, with adjustment for covariates that remained imbalanced after matching. Exposures: Individuals who initiated care through the RAAM model (including assessment, pharmacotherapy, brief counseling, harm reduction, triage to appropriate level of care, navigation to community services and primary care, and related care) were compared with individuals who did not receive care through the RAAM model. Main Outcomes and Measures: The primary outcome was a composite measure of ED visits for any reason, hospitalization for any reason, and all-cause mortality (all measured up to 30 days after index date). Outcomes up to 90 days after index date, as well as outcomes looking at opioid-related ED visits and hospitalizations, were also assessed. Results: In analyses of the sample of 876 patients formed using propensity score matching, 440 in the RAAM group (mean [SD] age, 36.5 [12.6] years; 276 [62.7%] male) and 436 in the control group (mean [SD] age, 36.8 [13.8] years; 258 [59.2%] male), the pooled odds ratio (OR) for the primary, 30-day composite outcome of all-cause ED visit, hospitalization, or mortality favored the RAAM model (OR, 0.68; 95% CI, 0.50-0.92). Analysis of the same outcome for opioid-related reasons only also favored the RAAM intervention (OR, 0.47; 95% CI, 0.29-0.76). Findings for the individual events of hospitalization, ED visit, and mortality at both 30-day and 90-day follow-up also favored the RAAM model, with comparisons reaching statistical significance in most cases. Conclusions and Relevance: In this cohort study of individuals with POU, RAAM clinics were associated with reductions in ED visits, hospitalizations, and mortality. These findings provide valuable evidence toward a broadened adoption of the RAAM model in other regions of North America and beyond.

Designs, facilitators, barriers, and lessons learned during the implementation of emergency department led virtual urgent care programs in Ontario, Canada.

Introduction: Virtual patient care has seen incredible growth since the beginning of the COVID-19 pandemic. To provide greater access to safe and timely urgent care, in the fall of 2020, the Ministry of Health introduced a pilot program of 14 virtual urgent care (VUC) initiatives across the province of Ontario. The objective of this paper was to describe the overall design, facilitators, barriers, and lessons learned during the implementation of seven emergency department (ED) led VUC pilot programs in Ontario, Canada. Methods: We assembled an expert panel of 13 emergency medicine physicians and researchers with experience leading and implementing local VUC programs. Each VUC program lead was asked to describe their local pilot program, share common facilitators and barriers to adoption of VUC services, and summarize lessons learned for future VUC design and development. Results: Models of care interventions varied across VUC pilot programs related to triage, staffing, technology, and physician remuneration. Common facilitators included local champions to guide program delivery, provincial funding support, and multi-modal marketing and promotions. Common barriers included behaviour change strategies to support adoption of a new service, access to high-quality information technology to support new workflow models that consider privacy, risk, and legal perspectives, and standardized data collection which underpin overall objective impact assessments. Conclusions: These pilot programs were rapidly implemented to support safe access to care and ED diversion of patients with low acuity issues during the COVID-19 pandemic. The heterogeneity of program implementation respects local autonomy yet may present challenges for sustainability efforts and future funding considerations.

Buprenorphine/naloxone induction in a Canadian emergency department with rapid access to community-based addictions providers.

OBJECTIVES: Opioid-related emergency department (ED) visits have increased significantly in recent years. Our objective was to evaluate an ED-initiated buprenorphine/naloxone program, which provided rapid access to an outpatient community-based addictions clinic, for patients in opioid withdrawal. METHODS: A retrospective chart review was completed within a health system encompassing four community EDs in Ontario, Canada. Patients were screened for opioid withdrawal between April 2017-December 2017 and offered buprenorphine/naloxone treatment and referral to outpatient addictions follow-up. The main outcome measure was treatment retention in the six-month period after the index visit. RESULTS: The overall sample (N = 49) showed high healthcare utilization in the year prior to the index ED visit. 88% of patients (n = 43) consented to ED-initiated buprenorphine/naloxone and were referred to outpatient addictions follow-up, with 54% attending the initial follow-up visit. In the 6-month follow-up period from the index ED visit, 35% of patients were receiving ongoing buprenorphine/naloxone treatment and 2.3% were weaned off opioids. Patients with ongoing treatment had significantly lower number of ED visits at 3 and 6 months (3 and 10, respectively) compared to patients who did not show up for outpatient follow-up (28, 40) or started/stopped treatment (23, 41). CONCLUSIONS: Screening for opioid use disorder in the ED and initiating buprenorphine/naloxone treatment with rapid referral to an outpatient community-based addictions clinic led to a 6-month treatment retention rate of 37% and a significant reduction in ED visits at 3 and 6 months. Buprenorphine/naloxone initiation in the ED appears to be an effective intervention, but further research is needed.

OBJECTIF: Le nombre de consultations aux services des urgences (SU) motivées par l'usage des opioïdes a augmenté de façon importante au cours des dernières années. L'étude visait à évaluer l'efficacité d'un programme de traitement des troubles afférents par la buprénorphine (BPN) et la naloxone, entrepris au SU et suivi d'un accès rapide à des services communautaires de consultation externe pour le traitement de la dépendance chez les patients présentant un syndrome de sevrage aux opioïdes. MÉTHODE: Il s'agit d'un examen rétrospectif de dossiers médicaux, réalisé dans un réseau de santé constitué 4 SU communautaires, en Ontario, au Canada. Les patients présentant des symptômes de sevrage aux opioïdes ont d'abord été repérés entre avril 2017 et décembre 2017, puis se sont vu offrir un traitement par la BUP et la naloxone avec aiguillage vers un service de consultation externe pour le suivi. Le critère d'évaluation principal consistait en la poursuite du traitement au cours de la période de 6 mois suivant la consultation de référence. RÉSULTATS: L'analyse de l'échantillon global (n = 49) a révélé une forte utilisation des services de santé au cours de l'année précédant la consultation de référence au SU. Dans l'ensemble, 88% des patients (n = 43) ont accepté l'offre de traitement entrepris au SU, puis ont été dirigés vers un service de consultation externe pour le suivi; 54% de ces derniers sont allés à la première consultation. Durant le suivi de 6 mois après la consultation de référence au SU, 35% des patients étaient encore en traitement et 2,3% des participants étaient sevrés. Les patients encore fidèles au traitement ont connu un nombre significativement moins élevé de consultations au SU au bout de 3 mois et de 6 mois (3 et 10, respectivement) que les patients qui ne sont pas présentés au service de consultation externe (28, 40) ou qui ont entrepris le traitement mais qui ne l'ont pas poursuivi (23, 41). CONCLUSION: Le dépistage des troubles liés à l'usage des opioïdes, au SU, et l'instauration du traitement par la BUP et la naloxone avec aiguillage rapide vers un service communautaire de consultation externe pour le traitement de la dépendance se sont traduits par un taux de rétention des patients de 37% au bout de 6 mois et par une réduction significative du nombre de consultations au SU au bout de 3 mois et de 6 mois. L'instauration du traitement au SU semble donc une intervention efficace, mais il faudrait poursuivre la recherche sur le sujet.

Fetal pericardial teratoma: presentation of two cases and review of literature.

We present the fetal ultrasound and echocardiographic findings and clinical outcome of two fetuses with intrapericardial teratoma encountered in our institution. In the first (diagnosed at 19 weeks of gestation) case there was elective termination of pregnancy; in the second case (diagnosed at 24 weeks), a pericardio-amniotic shunt was placed after reaccumulation of fluid following pericardiocentesis. We review the published experience of intrapericardial teratomas, focusing on the diagnosis, fetal echocardiographic findings, and outcome with and without prenatal intervention.