Literature Collection

BACKGROUND AND OBJECTIVES: Elder abuse (EA) is common and has significant health impacts. New initiatives seek to capitalize on opportunities to respond to EA from within the healthcare system, but little is known about what clinicians may need to be successful in these efforts. Our objective was to understand perceived barriers and facilitators to managing all phases of EA within an integrated healthcare system from the perspectives of frontline clinicians from a range of different disciplines. RESEARCH DESIGN AND METHODS: Thirty-seven clinicians (10 social workers, 9 physicians, 7 psychologists, 6 nurses, and 5 advanced practice providers) from different clinical sites within 2 large Veterans Health Administration (VHA) medical centers participated in semistructured interviews. The interview guide was designed to elicit facilitators and barriers to discrete stages in the process of addressing EA, including detection, reporting, intervention, and monitoring. Transcripts were coded using deductive (based on a prespecified conceptual model) and inductive approaches and analyzed using thematic analysis. RESULTS: Most (78%) participants were women, ranging in age from 33 to 64 years, and practicing in a variety of settings (e.g., primary care and emergency department) with between 4 and 25 years of VHA experience. We identified 5 interrelated themes that cut across the different stages of EA care: situational context (theme 1), degree of trust in familial and healthcare relationships (theme 2), extent of education and skills (theme 3), and existing system infrastructure (theme 4) all contributed to clinician empowerment and motivation toward action (theme 5). DISCUSSION AND IMPLICATIONS: Efforts to enhance skills training, build trusting relationships, and improve system infrastructure could help to equip clinicians to engage in healthcare system interventions to reduce harm from EA.

Patients in Opioid Substitution Treatment (OST) have increased mortality and morbidity, with circulatory conditions suggested to be a contributing factor. Since OST patients tend to have unmet physical healthcare needs, a small-scale intervention providing on-site primary healthcare (PHC) in OST clinics was implemented in Malmö, Sweden in 2016. In this study, we assessed registered circulatory conditions and healthcare utilization in OST patients with and without use of on-site PHC. Patients from four OST clinics in Malmö, Sweden, were recruited to a survey study in 2017-2018. Medical records for the participants were retrieved for one year prior to study participation (n = 192), and examined for circulatory diagnoses, examinations and follow-ups. Patients with and without on-site PHC were compared through descriptive statistics and univariate analyses. Eighteen percent (n = 34) of the sample had 1≤ registered circulatory condition, and 6% (n = 12) attended any clinical physiology examination or follow-up, respectively. Among patients utilizing on-site PHC (n = 26), the numbers were 27% (n = 7) for circulatory diagnosis, 15% (n = 4) for examinations, and 12% (n = 3) for follow-up. OST patients seem underdiagnosed in regard to their circulatory health. On-site PHC might be a way to diagnose and treat circulatory conditions among OST patients, although further research is needed.

INTRODUCTION: Recent studies from urban academic centers have shown the promise of emergency physician-initiated buprenorphine for improving outcomes in opioid use disorder (OUD) patients. We investigated whether emergency physician-initiated buprenorphine in a rural, community setting decreases subsequent healthcare utilization for OUD patients. METHODS: We performed a retrospective chart review of patients presenting to a community hospital emergency department (ED) who received a prescription for buprenorphine from June 15, 2018-June 15, 2019. Demographic and opioid-related International Classification of Diseases, 10th Revision, (ICD-10) codes were documented and used to create a case-matched control cohort of demographically matched patients who presented in a similar time frame with similar ICD-10 codes but did not receive buprenorphine. We recorded 12-month rates of ED visits, all-cause hospitalizations, and opioid overdoses. Differences in event occurrences between groups were assessed with Poisson regression. RESULTS: Overall 117 patients were included in the study: 59 who received buprenorphine vs 58 controls. The groups were well matched, both roughly 90% White and 60% male, with an average age of 33.4 years for both groups. Controls had a median two ED visits (range 0-33), median 0.5 hospitalizations (range 0-8), and 0 overdoses (range 0-3), vs median one ED visit (range 0-8), median 0 hospitalizations (range 0-4), and median 0 overdoses (range 0-3) in the treatment group. The incidence rate ratio (IRR) for counts of ED visits was 0.61, 95% confidence interval (CI), 0.49, 0.75, favoring medication-assisted treatment (MAT). For hospitalizations, IRR was 0.34, 95% CI, 0.22, 0.52 favoring MAT, and for overdoses was 1.04, 95% CI, 0.53, 2.07. CONCLUSION: Initiation of buprenorphine by ED providers was associated with lower 12-month ED visit and all-cause hospitalization rates with comparable overdose rates compared to controls. These findings show the ED's potential as an initiation point for medication-assisted treatment in OUD patients.

PURPOSE: The co-occurrence of substance use disorders and mental health disorders in adolescents, known as dual diagnosis, complicates treatment adherence, heightens relapse risk, and increases engagement in risky behaviors. This study contrasts these groups' healthcare utilization, interventions, and clinical profiles. METHODS: In a retrospective, longitudinal cohort study using the TriNetX Research Database, we analyzed data from 82 U.S. healthcare organizations. The study encompassed 1,757,913 adolescents aged 10 to 21 diagnosed with substance use disorders, mental health disorders, and a combination of both from 2004 to 2023. Propensity score matching was applied to adjust for demographic and clinical variables, assessing healthcare utilization, treatment initiation, and social challenges. RESULTS: Among 1,757,913 adolescents, 14.0 % (n = 246,776) had a dual diagnosis. Compared with isolated MHD, adolescents with DDx had significantly higher odds of emergency department use (OR 2.64, 95 % CI 2.27-2.70) and inpatient hospitalization (OR 2.73, 95 % CI 2.69-2.77). Relative to isolated SUD, DDx also showed elevated ED use (OR 1.56, 95 % CI 1.53-1.58) and inpatient care (OR 2.55, 95 % CI 2.50-2.61). Pharmacologic treatment initiation was more common in DDx, including antidepressants (53.1 % vs. 44.8 % MHD; OR 1.40, 95 % CI 1.38-1.42) and antipsychotics (35.5 % vs. 18.9 % MHD; OR 2.36, 95 % CI 2.33-2.39). DDx also demonstrated higher rates of social and environmental problems (19.3 % vs. 8.6 % MHD and 3.9 % SUD). DISCUSSION: Adolescents with dual diagnoses constitute a distinct demographic with intricate clinical profiles and heightened healthcare needs, emphasizing the need for integrated care approaches that address clinical symptoms and social determinants. Early identification and comprehensive interventions are crucial to improving outcomes.