Buprenorphine Prescribing and Challenges Faced Among National Health Service Corps Clinicians.

Importance: The National Health Service Corps (NHSC) Loan Repayment Program (LRP) expansion in fiscal year (FY) 2019 intended to improve access to medication for opioid use disorder (MOUD) by adding more clinicians who could prescribe buprenorphine. However, some clinicians still face barriers to prescribing, which may vary between rural and nonrural areas. Objective: To examine the growth in buprenorphine prescribing by NHSC clinicians for Medicaid beneficiaries during the NHSC LRP expansion and describe the challenges to prescribing that persist in rural and nonrural areas. Design, Setting, and Participants: This cross-sectional study analyzed preexpansion and postexpansion Medicaid claims data to evaluate the percentage of prescriptions of buprenorphine filled during FY 2017 through 2021. This study also analyzed challenges and barriers to prescribing MOUD between rural and urban areas, using results from annual surveys conducted with NHSC clinicians and sites from FY 2019 through FY 2021. Exposure: Prescribing of buprenorphine by NHSC clinicians. Main Outcomes and Measures: The main outcomes were the percentage and number of Medicaid beneficiaries with opioid use disorder (OUD) who filled a prescription for buprenorphine before and after the LRP expansion and the challenges NHSC clinicians and sites faced in providing substance use disorder and OUD services. Survey results were analyzed using descriptive statistics. Results: During FYs 2017 through 2021, 7828 NHSC clinicians prescribed buprenorphine (standard LRP: mean [SD] age, 38.1 [8.4] years and 4807 females [78.9%]; expansion LRPs: mean [SD] age, 39.4 [8.1] years and 1307 females [75.0%]). A total of 3297 NHSC clinicians and 4732 NHSC sites responded to at least 1 survey question to the 3 surveys. The overall percentage of Medicaid beneficiaries with OUD who filled a prescription for buprenorphine during the first 2.5 years post expansion increased significantly from 18.9% before to 43.7% after expansion (an increase of 123 422 beneficiaries; P < .001). The percentage more than doubled among beneficiaries living in areas with a high Social Vulnerability Index score (from 17.0% to 36.7%; an increase of 31 964) and among beneficiaries living in rural areas (from 20.8% to 55.7%; an increase of 45 523). However, 773 of 2140 clinicians (36.1%; 95% CI, 33.6%-38.6%) reported a lack of mental health services to complement medication for OUD treatment, and 290 of 1032 clinicians (28.1%; 95% CI, 24.7%-31.7%) reported that they did not prescribe buprenorphine due to a lack of supervision, mentorship, or peer consultation. Conclusions and Relevance: These findings suggest that although the X-waiver requirement has been removed and Substance Abuse and Mental Health Services Administration guidelines encourage all eligible clinicians to screen and offer patients with OUD buprenorphine, as permissible by state law, more trained health care workers and improved care coordination for counseling and referral services are needed to support comprehensive OUD treatment.

Role of the National Health Service Corps in Delivering Substance Use Disorder Treatment in Underserved Communities.

OBJECTIVE: To help address the opioid epidemic, the U.S. Health Resources and Services Administration expanded the National Health Service Corps (NHSC) to include two new loan repayment programs (LRPs)-the Substance Use Disorder LRP and the Rural Community LRP-to supplement the existing standard LRP. In this article, the authors aimed to describe the role of these NHSC programs in addressing workforce shortages and providing substance use disorder treatment, including for opioid use disorder, in underserved areas. METHODS: Administrative data on NHSC clinician locations were merged with county-level data to characterize the communities served by NHSC clinicians. Primary data from surveys and key informant interviews with NHSC site administrators (N=9) and clinicians (N=9) were used to describe changes in NHSC clinician service delivery due to the COVID-19 pandemic. RESULTS: The NHSC LRP expansion increased the number of clinicians providing behavioral health treatment in underserved areas, especially rural areas. A majority of NHSC sites surveyed have increased their provision of substance use disorder treatment since the COVID-19 pandemic began. CONCLUSIONS: This article demonstrates the valuable role of these NHSC programs as resources that policy makers can use to mitigate the challenges of health care workforce shortages and burnout.

A Mixed-Methods Study of Teaching Health Center Residents' Experiences of Mentorship, Career Planning, and Postresidency Practice Environments.

PURPOSE: The Teaching Health Center (THC) Graduate Medical Education program enables primary care physicians to train in community-based, underserved settings by shifting the payment structure and training environment for graduate medical education. To understand how THCs have successfully trained primary care physicians who practice in community-based settings, the authors conducted a mixed-methods exploratory study to examine THC residency graduates' experiences of mentorship and career planning during their residencies, perceptions of preparation for postresidency practice, and how these experiences were related to postresidency practice environments. METHOD: Surveys were conducted for all 804 graduating THC residents nationally, 2014-2017 (533 respondents, 66% response rate). Three quantitative outcomes were measured: graduates' perceptions of preparation for practice after residency (Likert scale), satisfaction with mentorship and career planning (Likert scale), and characteristics of postresidency practice environment (open-ended). A qualitative analysis of open-text survey answers, using thematic content analysis, was also conducted. RESULTS: Most THC graduates (68%) were satisfied with their mentorship and career planning experience and generally felt prepared for postresidency practice in multiple settings (78%-93%). Of the 533 THC graduates who provided information about their practice environment, 445 (84%) were practicing in primary care; nationally, 64% of physicians who completed primary care residencies practiced in primary care. Of the 445 THC graduates practicing in primary care, 12% practiced in rural areas, compared with 7% of all physicians. Just over half of THC graduates (51%) practiced in medically underserved areas, compared with 39% of all physicians. CONCLUSIONS: This study offers early evidence that the THC model produces and retains primary care physicians who are well prepared to practice in underserved areas. Given these promising findings, there appears to be a substantial benefit to growing the THC program. However, the program continues to face uncertainty around ongoing, stable funding.

The effect of patient age on perceived resuscitation outcomes by practitioners.

BACKGROUND: When health care practitioners assist patients with decisions about advance directives, the risks and benefits of resuscitation options are often discussed. Whether practitioners have accurate perceptions about in-hospital resuscitation success rates is not known, nor is the effect of patient age on these perceptions. Age on its own has not been definitively associated with decreased inpatient survival after resuscitation. The goal of this study was to compare perceived resuscitation success rates with the actual observed rates at our hospital and to assess the effect of patient age on the perceived rates. METHODS: A survey-based observational study of on-duty hospital-based faculty, internal medicine resident physicians, and critical care nurses was performed over a week-long recruitment period to estimate their perception of in-hospital resuscitation success rates for patients of different ages. The survey response rate was 100%. RESULTS: Patient survival to hospital discharge following in-hospital resuscitation during a three-year period at New Hanover Regional Medical Center was 29.22% for patients < 70 years old and 20.13% for patients > or = 70. The perceived in-hospital resuscitation success rates were 38.76% for patients < 70 and 21.24% for patients > or = 70. This corresponds to a statistically significant overestimation of resuscitation success rates for patients < 70 years old (p < 0.001), although predictions were fairly accurate for patients > or = 70. When posed with one of two clinical scenarios where the only different variable was patient age, participants were statistically more likely to predict success for the younger patient. Subgroup analysis showed general agreement in the estimates between the three major types of practitioners, and factors such as length of experience in their current position and time since their last Advanced Cardiac Life Support (ACLS) recertification course did not have a significant impact on these perceptions. CONCLUSIONS: Practitioners may overestimate resuscitation success rates in patients younger than 70. Disseminating information about ACLS success rates to clinicians, and what factors affect or do not affect these rates, seems essential.

The geographic alignment of primary care Health Professional Shortage Areas with markers for social determinants of health.

BACKGROUND: The Health Resources and Services Administration (HRSA), an agency within the U.S. Department of Health and Human Services (HHS), works to ensure accessible, quality, health care for the nation's underserved populations, especially those who are medically, economically, or geographically vulnerable. HRSA-designated primary care Health Professional Shortage Areas (pcHPSAs) provide a vital measure by which to identify underserved populations and prioritize locations and populations lacking access to adequate primary and preventive health care-the foundation for advancing health equity and maintaining health and wellness for individuals and populations. However, access to care is a complex, multifactorial issue that involves more than just the number of health care providers available, and pcHPSAs alone cannot fully characterize the distribution of medically, economically, and geographically vulnerable populations. METHODS AND FINDINGS: In this county-level analysis, we used descriptive statistics and multiple correspondence analysis to assess how HRSA's pcHPSA designations align geographically with other established markers of medical, economic, and geographic vulnerability. Reflecting recognized social determinants of health (SDOH), markers included demographic characteristics, race and ethnicity, rates of low birth weight births, median household income, poverty, educational attainment, and rurality. Nationally, 96 percent of U.S. counties were either classified as whole county or partial county pcHPSAs or had one or more established markers of medical, economic, or geographic vulnerability in 2017, suggesting that at-risk populations were nearly ubiquitous throughout the nation. Primary care HPSA counties in HHS Regions 4 and 6 (largely lying within the southeastern and south central United States) had the most pervasive and complex patterns in population risk. CONCLUSION: HHS Regions displayed unique signatures with respect to SDOH markers. Descriptive and analytic findings from our work may help inform health workforce and health care planning at all levels, and, by illustrating both the complexity of and differences in county-level population characteristics in pcHPSA counties, our findings may have relevance for strengthening the delivery of primary care and addressing social determinants of health in areas beset by provider shortages.

Factor structure and psychometric properties of the Children's Negative Cognitive Error Questionnaire with a clinically depressed adolescent sample.

The factor structure and psychometric properties of the Children's Negative Cognitive Error Questionnaire (CNCEQ) were examined with 427 adolescents ages 12 to 18 (193 boys) with current major depressive disorder. Results of confirmatory factor analysis supported a four-factor model comprised of three content area factors (i.e., social, academic, athletic) and a general factor. Internal consistencies ranged between .84 and .94 for the total and three content area scores. Girls scored significantly higher than boys on all factors, but no age differences on the factors were found. Convergent and discriminant validity of the CNCEQ were supported. Results did not support the original subscales organized by type of cognitive distortion (e.g., catastrophizing, overgeneralizing). Findings indicated that the CNCEQ would be a useful clinical tool for assessing cognitive symptoms within relevant domains of functioning (e.g., social, academic) of depressed youth.

Primary Care Residents in Teaching Health Centers: Their Intentions to Practice in Underserved Settings After Residency Training.

PURPOSE: To describe the residents who chose to train in teaching health centers (THCs), which are community-based ambulatory patient care sites that sponsor primary care residencies, and their intentions to practice in underserved settings. METHOD: The authors surveyed all THC residents training in academic years 2013-2014, 2014-2015, and 2015-2016, comparing their demographic characteristics with data for residents nationally, and examined THC residents' intentions to practice in underserved settings using logistic regression analysis. RESULTS: The overall survey response rate was 89% (1,031/1,153). THC resident respondents were similar to residents nationally in family medicine, geriatrics, internal medicine, obstetrics-gynecology, pediatrics, and psychiatry in terms of gender, age, race, and ethnicity. Twenty-nine percent (283) of respondents came from a rural background, and 46% (454) had an educationally and/or economically disadvantaged background. More than half (524; 55%) intended to practice in an underserved setting on completion of their training. Respondents were more likely to intend to practice in an underserved area if they came from a rural background (odds ratio 1.58; 95% confidence interval 1.08, 2.32) or disadvantaged background (odds ratio 2.81; 95% confidence interval 1.91, 4.13). CONCLUSIONS: THCs attract residents from rural and/or disadvantaged backgrounds who seem to be more inclined to practice in underserved areas than those from urban and economically advantaged roots. THC residents' intentions to practice in underserved areas indicate that primary care training programs sponsored by community-based ambulatory patient care sites represent a promising strategy to improve the U.S. health care workforce distribution.

Family characteristics of anxious ADHD children: preliminary results.

OBJECTIVE: To investigate the family environments of children in a community sample with ADHD and co-occurring anxiety. METHOD: Family Environment Scale, Behavioral Assessment System for Children, and Structured Clinical Interview are administered to parents of children with ADHD with and without anxiety. RESULTS: ADHD families are uniformly less cohesive and expressive and possess more conflict than families representing the community sample. In contrast to community or nonanxious ADHD families, anxious ADHD families do not encourage independence and tend to be distinctly less assertive, self-sufficient, and autonomous. Although anxious and nonanxious ADHD children tend to have a uniformly high incidence of maternal ADHD, mothers of anxious ADHD children tend to display a much higher incidence of substance/alcohol abuse than either nonanxious or community participants. CONCLUSION: Findings are consistent with the notion that an insular, dependent, and somewhat controlling family environment characterizes families of children with ADHD and comorbid childhood anxiety.

Anxiety and depression symptoms in psychometrically identified schizotypy.

The neurodevelopmental vulnerability for schizophrenia appears to be expressed across a dynamic continuum of adjustment referred to as schizotypy. This model suggests that nonpsychotic schizotypic individuals should exhibit mild and transient forms of symptoms seen in full-blown schizophrenia. Given that depression and anxiety are reported to be comorbid with schizophrenia, the present study examined the relationship of psychometrically defined schizotypy with symptoms of depression and anxiety in a college student sample (n=1258). A series of confirmatory factor analyses indicated that a three-factor solution of positive schizotypy, negative schizotypy, and negative affect provided the best solution for self-report measures of schizotypy, anxiety, and depression. As hypothesized, the model indicated that symptoms of depression and anxiety are more strongly associated with the positive-symptom dimension of schizotypy than with the negative-symptom dimension. This is consistent with studies of schizophrenic patients and longitudinal findings that positive-symptom schizotypes are at risk for both mood and non-mood psychotic disorders, while negative-symptom schizotypes appear more specifically at risk for schizophrenia-spectrum disorders.

Co-occurring psychiatric disorders in children and adolescents with Tourette syndrome.

More than half of all children and adolescents with Tourette syndrome show evidence of psychiatric comorbidity, exhibiting symptoms of attention-deficit hyperactivity disorder (ADHD), obsessive-compulsive disorder, and other anxiety and mood disorders. Although the prevalence of co-occurring conditions varies depending on the clinical setting, it is crucial for clinicians to be familiar with these disorders because they are often more impairing than tics and can influence the initial treatment choice. Left untreated, these conditions can negatively affect important developmental outcomes, such as academic and social functioning. We review the most common co-occurring disorders, the relationship of these co-occurring disorders to Tourette syndrome, and treatment recommendations for co-occurring conditions when tic symptoms are present.

The Benefits of Physician Training Programs for Rural Communities: Lessons Learned from the Teaching Health Center Graduate Medical Education Program.

Rural communities disproportionately face preventable chronic diseases and death from treatable conditions. Health workforce shortages contribute to limited health care access and health disparities. Efforts to address workforce shortages have included establishing graduate medical education programs with the goal of recruiting and retaining physicians in the communities in which they train. However, rural communities face a number of challenges in developing and maintaining successful residency programs, including concerns over financial sustainability and the integration of resident trainees into existing clinical practices. Despite these challenges, rural communities are increasingly interested in investing in residency programs; those that are successful see additional benefits in workforce recruitment, access, and quality of care that have immediate and direct impact on the health of rural communities. This commentary examines the challenges and benefits of rural residency programs, drawing from lessons learned from the Health Resources and Services Administration's Teaching Health Center Graduate Medical Education program.

The Health Resources and Services Administration diversity data collection.

The Health Resources and Services Administration maintains a strong emphasis on increasing the diversity of the health-care workforce through its grant programs. Increasing the diversity of the workforce is important for reducing health disparities in the population caused by socioeconomic, geographic, and race/ethnicity factors because evidence suggests that minority health professionals are more likely to serve in areas with a high proportion of underrepresented racial and ethnic minority groups. The data show success in increasing the diversity of enrollees in five nursing programs.

Internal consistency and discriminant validity of a delay-discounting task with an adult self-reported ADHD sample.

OBJECTIVE: The purpose of this research was to evaluate the reliability and discriminant validity of a behavioral task of impulsivity, the delay-discounting task. METHOD: Young adults were asked to report ADHD diagnostic status and to complete the delay-discounting task. The internal consistency of the task was determined, task performances of individuals with and without self-reported ADHD were compared, and the ability of this task to discriminate between participants with and without self-reported ADHD was assessed. RESULTS: The delay-discounting task showed very good to excellent internal consistency. Furthermore, participants with self-reported ADHD responded to the task in a more impulsive manner than did non-ADHD participants. Finally, moderate discriminant validity for detecting self-reported ADHD using this task was found. CONCLUSION: Findings showed that the delay-discounting task is a promising task for both clinical research and practice as it has strong reliability overall and has moderate discriminant ability for self-reported ADHD in young adults.

Clinical Characteristics of Children and Adolescents with a Primary Tic Disorder.

The clinical characteristics and rates of co-occurring psychiatric conditions in youth seeking treatment for a chronic tic disorder (CTD) were examined. Children and adolescents (N = 126) with a primary CTD diagnosis were recruited for a randomized controlled treatment trial. An expert clinician established diagnostic status via semi-structured interview. Participants were male (78.6%), Caucasians (84.9%), mean age 11.7 years (SD = 2.3) with moderate-to-severe tics who met criteria for Tourette's disorder (93.7%). Common co-occurring conditions included attention-deficit/hyperactivity disorder (ADHD; 26%), social phobia (21%), generalized anxiety disorder (20%), and obsessive-compulsive disorder (OCD; 19%). Motor and vocal tics with greater intensity, complexity, and interference were associated with increased impairment. Youth with a CTD seeking treatment for tics should be evaluated for non-OCD anxiety disorders in addition to ADHD and OCD. Despite the presence of co-occurring conditions, children with more forceful, complex, and/or directly interfering tics may seek treatment to reduce tic severity.

Treatment response in depressed adolescents with and without co-morbid attention-deficit/hyperactivity disorder in the Treatment for Adolescents with Depression Study.

OBJECTIVE: In the Treatment for Adolescents with Depression Study (TADS), fluoxetine (FLX) and the combination of fluoxetine with cognitive-behavioral therapy (COMB) had superior improvement trajectories compared to pill placebo (PBO), whereas cognitive-behavioral therapy (CBT) was not significantly different from PBO. Because attention-deficit/hyperactivity disorder (ADHD) and major depressive disorder (MDD) frequently co-exist, we examined whether ADHD moderated these outcomes in TADS. METHOD: A total of 439 adolescents with MDD, 12-17 years old, were randomized to FLX, CBT, COMB, or PBO. Random coefficients regression models examined depression improvement in 377 depressed youths without ADHD and 62 with ADHD, including 20 who were treated with a psychostimulant. RESULTS: Within the ADHD group, the improvement trajectories of the three active treatments were similar, all with rates of improvement greater than PBO. For those without ADHD, only COMB had a rate of improvement that was superior to PBO. CONCLUSIONS: Co-morbid ADHD moderated treatment of MDD. CBT alone or FLX alone may offer benefits similar to COMB in the treatment of MDD in youths with co-morbid MDD and ADHD, whereas monotherapy may not match the benefits of COMB for those without ADHD. The ADHD subgroup analysis presented in this paper is exploratory in nature because of the small number of youths with ADHD in the sample. CLINICAL TRIAL REGISTRY: www.clinicaltrials.gov Identifier: NCT00006286. The TADS protocol and all of the TADS manuals are available on the Internet at https://trialweb.dcri.duke.edu/tads/index.html .