Literature Collection

INTRODUCTION: US opioid overdoses and deaths continue to increase, despite historic national investment to mitigate risk and improve access to evidence-based treatment. Unfortunately, implementation of emergency department (ED) buprenorphine - an effective medical treatment for opioid use disorder (OUD) - has been limited. Our objective was to assess the effectiveness of an electronic health record (EHR)-integrated, interruptive clinical decision support (CDS) tool to improve rates of ED initiated OUD treatment. METHODS: This is an observational, pre-post study of a CDS tool designed to identify and facilitate treatment of patients with OUD using electronic health record data. Patients were included if treated at our urban, academic ED between May 1, 2022, and November 8, 2023. The CDS triggered based on a rules-based algorithm using routinely collected EHR data which were identified from a previously validated EHR OUD phenotype. Outcomes are organized under a modified RE-AIM framework, with the primary outcome, Effectiveness, measured by the proportion of OUD patients receiving buprenorphine (administered/prescribed; filled prescriptions). Secondary outcomes include patient Reach, clinician Adoption, and fidelity to Implementation. Chi Square tests and Bayesian structural time-series models evaluate differences in outcomes before and after CDS implementation (CausalImpact package v1.3.0 in R v4.4.0). RESULTS: There were 171,221 total ED visits during the study period. Patient characteristics before and after CDS implementation were similar. CDS triggered in 4.7 % (2754/58,173) of encounters after initiation of intervention, reaching 116 unique emergency medicine providers and 2566 ED patients. Clinicians adopted the CDS, accessing the OUD treatment pathway link or ordering a social work consult for substance use, in 27 % (1266/4746) of CDS alerts. When compared to the pre-implementation period, CDS implementation was associated with increased buprenorphine administration in the ED by 31 % (95 % CI: 16-47 %, p = 0.001), buprenorphine prescribing from the ED by 20 % (95 % CI: 5-38 %, p = 0.007), and the buprenorphine fill rate at an affiliated ED pharmacy by 17 % (95 % CI: 1-36 %, p = 0.017). CONCLUSIONS: Implementation of an EHR-integrated, CDS was associated with increased ED buprenorphine administration, prescribing, and prescription fills among ED patients with OUD. Further efforts are needed to assess maintenance strategies that improve adoption, minimize interruptiveness, and optimize workflow congruence.

Mathematical and computational models are often used to forecast respiratory infectious disease burden, including to inform healthcare capacity. We aimed to characterize pathways of clinical progression associated with SARS-CoV-2, influenza, and respiratory syncytial virus (RSV) infections using data from patients aged 0 to >90 years in an integrated healthcare system, whose encounters were monitored across all levels of acuity spanning virtual, ambulatory, and inpatient care settings. Using parametric survival models, we estimated probabilities of progression and distributions of time to progression from each setting to all higher-acuity settings on a cascade encompassing the following classes of events or encounters: symptoms onset; diagnostic testing; telehealth or other virtual care appointment; outpatient physician office visit; urgent care presentation; emergency department presentation; hospital admission; mechanical ventilation; and death. Our analyses included data from 59,668, 22,705, and 1,668 episodes associated with positive SARS-CoV-2, influenza, and RSV tests, respectively, between 1 April 2023 and 31 March 2024. First clinical encounters occurred in inpatient settings for only 4.7%, 3.4%, and 18.7% of SARS-CoV-2, influenza, and RSV episodes, respectively, with median times (interquartile range) of 6.8 (3.6-13.2), 6.6 (3.5-12.1), and 6.4 (3.8-10.6) days from symptoms onset to admission. Overall, 7.9% of SARS-CoV-2 episodes, 5.8% of influenza episodes, and 33.8% of RSV episodes resulted in inpatient admission, ventilation, or death. Between 40.4-62.1%, 71.6-87.3%, and 47.9-58.7% of SARS-CoV-2, influenza, and RSV infections, respectively, had encounters in lower-acuity virtual care, outpatient, or urgent care settings. For all three viruses, the proportions of cases receiving care at each level of acuity increased with older age and greater numbers of comorbid conditions. Median durations of hospital stay were 4.2 (2.6, 7.3), 4.0 (2.3, 6.8), and 4.3 (2.5, 7.4) days for SARS-CoV-2, influenza, and RSV episodes resulting in admission. These estimates provide a basis for modeling real-world clinical care requirements and the progression of respiratory viral infections.

BACKGROUND: While the number of digital therapeutics (DTx) has proliferated, there is little real-world research on the characteristics of providers recommending DTx, their recommendation behaviors, or the characteristics of patients receiving recommendations in the clinical setting. OBJECTIVE: The aim of this study was to characterize the clinical and demographic characteristics of patients receiving DTx recommendations and describe provider characteristics and behaviors regarding DTx. METHODS: This retrospective cohort study used electronic health record data from a large, integrated health care delivery system. Demographic and clinical characteristics of adult patients recommended versus not recommended DTx by a mental health provider between May 2020 and December 2021 were examined. A cross-sectional survey of mental health providers providing these recommendations was conducted in December 2022 to assess the characteristics of providers and recommendation behaviors related to DTx. Parametric and nonparametric tests were used to examine statistical significance between groups. RESULTS: Of 335,250 patients with a mental health appointment, 53,546 (16%) received a DTx recommendation. Patients recommended to DTx were younger, were of Asian or Hispanic race or ethnicity, were female, were without medical comorbidities, and had commercial insurance compared to those without a DTx recommendation (P<.001). More patients receiving a DTx recommendation had anxiety or adjustment disorder diagnoses, but less had depression, bipolar, or psychotic disorder diagnoses (P<.001) versus matched controls not recommended to DTx. Overall, depression and anxiety symptom scores were lower in patients recommended to DTx compared to matched controls not receiving a recommendation, although female patients had a higher proportion of severe depression and anxiety scores compared to male patients. Provider survey results indicated a higher proportion of nonprescribers recommended DTx to patients compared to prescribers (P=.008). Of all providers, 29.4% (45/153) reported using the suggested internal electronic health record-based tools (eg, smart text) to recommend DTx, and of providers recommending DTx resources to patients, 64.1% (98/153) reported they follow up with patients to inquire on DTx benefits. Only 38.4% (58/151) of respondents report recommending specific DTx modules, and of those, 58.6% (34/58) report following up on the impact of these specific modules. CONCLUSIONS: DTx use in mental health was modest and varied by patient and provider characteristics. Providers do not appear to actively engage with these tools and integrate them into treatment plans. Providers, while expressing interest in potential benefits from DTx, may view DTx as a passive strategy to augment traditional treatment for select patients.

OBJECTIVE: Posttraumatic stress disorder (PTSD) and bipolar disorder are common in primary care. Evidence supports collaborative care in primary care settings to treat depression and anxiety, and recent studies have evaluated its effectiveness in treating complex conditions such as PTSD and bipolar disorder. This study aimed to examine how primary care clinicians experience collaborative care for patients with these more complex psychiatric disorders. METHODS: The authors conducted semistructured interviews with 22 primary care clinicians participating in a pragmatic trial that included telepsychiatry collaborative care (TCC) to treat patients with PTSD or bipolar disorder in rural or underserved areas. Analysis utilized a constant comparative method to identify recurring themes. RESULTS: Clinicians reported that TCC improved their confidence in managing medications for patients with PTSD or bipolar disorder and supported their ongoing learning and skill development. Clinicians also reported improvements in patient engagement in care. Care managers were crucial to realizing these benefits by fostering communication within the clinical team while engaging patients through regular outreach. Clinicians valued TCC because it included and supported them in improving the care of patients' mental health conditions, which opened opportunities for clinicians to enhance care and address co-occurring general medical conditions. Overall, benefits of the TCC model outweighed its minimal burdens. CONCLUSIONS: Clinicians found that TCC supported their care of patients with PTSD or bipolar disorder. This approach has the potential to extend the reach of specialty mental health care and to support primary care clinicians treating patients with these more complex psychiatric disorders.

BACKGROUND: Many allied health services now provide both telehealth and in-person services following a rapid integration of telehealth as a response to the COVID-19 pandemic. However, little is known about how decisions are made about which clinical appointments to provide via telehealth versus in person. OBJECTIVE: The aim of this study is to explore clinicians' decision-making when contemplating telehealth for their clients, including the factors they consider and how they weigh up these different factors, and the clinicians' perceptions of telehealth utility beyond COVID-19 lockdowns. METHODS: We used reflexive thematic analysis with data collected from focus groups with 16 pediatric community-based allied health clinicians from the disciplines of speech-language pathology, occupational therapy, social work, psychology, and counseling. RESULTS: The findings indicated that decision-making was complex with interactions across 4 broad categories: technology, clients and families, clinical services, and clinicians. Three themes described their perceptions of telehealth use beyond COVID-19 lockdowns: "flexible telehealth use," "telehealth can be superior to in-person therapy," and "fear that in-person services may be replaced." CONCLUSIONS: The findings highlight the complexity of decision-making in a community-allied health setting and the challenges experienced by clinicians when reconciling empirical evidence with their own clinical experience.

BACKGROUND: Co-occurring substance use disorders (SUDs) among individuals with opioid use disorder (OUD) are associated with additional impairment, overdose, and death. This study examined characteristics of patients who have OUD with and without co-occurring SUDs in rural primary care clinics. METHODS: Secondary analysis used electronic health record (EHR) data from six rural primary care clinics, including demographics, diagnoses, encounters, and prescriptions of medication for OUD (MOUD), as well as EHR data from an external telemedicine vendor that provided MOUD to some clinic patients. The study population included all adult patients who had a visit to the participating clinics from October 2019 to January 2021. RESULTS: We identified 1164 patients with OUD; 72.6 % had OUD only, 11.5 % had OUD and stimulant use disorder (OUD + StUD), and 15.9 % had OUD and other non-stimulant substance use disorder (OUD + Other). The OUD + StUD group had the highest rates of hepatitis C virus (25.4 % for OUD + StUD, 17.8 % for OUD + Other, and 7.5 % for OUD Only; p < 0.001) and the highest rates of mental health disorders (78.4 %, 69.7 %, and 59.9 %, respectively; p < 0.001). Compared to the OUD Only group, patients in the OUD + StUD and OUD + Other groups were more likely to receive telehealth services provided by clinic staff, in-clinic behavioral health services, and in-clinic MOUD. The OUD + StUD group had the highest proportion of referrals to the external telemedicine vendor. CONCLUSIONS: More than 27 % of patients with OUD in rural primary care clinics had other co-occurring SUDs, and these patients received more healthcare services than those with OUD only. Future studies should examine variations in outcomes associated with these other services among patients with OUD and co-occurring SUDs.