Literature Collection

OBJECTIVE: People with serious mental illness (i.e., disabling psychotic, mood, and other disorders) develop chronic medical diseases early in life. This study aimed to examine the effects of integrating primary care into community mental health centers (CMHCs; reverse integrated care) on service use among young adults with serious mental illness who may benefit from early intervention. METHODS: This retrospective cohort analysis used Medicaid claims of 945 people with serious mental illness (ages 18-40) in CMHC care from 2020 to 2022-315 in reverse integrated care and 630 propensity score matched participants in comparison care (i.e., not reverse integrated care). Logistic regression, adjusted for participant characteristics, enrollment quarter, and past service use, assessed outcomes in the 6 months after enrollment. RESULTS: Participants' mean±SD age was 32.56 ± 7.84 years; 29% had a diagnosis of schizophrenia, 40% had a co-occurring substance use disorder, 33% had a medical emergency department (ED) visit in the 6 months before enrollment, and all were enrolled in CMHC care at baseline. During follow-up, participants in reverse integrated care were more likely to have an outpatient medical visit (65% vs. 58%; adjusted odds ratio [AOR]=1.54, p=0.005) and were less likely to have a medical ED visit (26% vs. 33%; AOR=0.70, p=0.035) than those in comparison care. CONCLUSIONS: Integrating primary care into CMHC services may increase access to outpatient medical care and reduce ED visits for medical reasons among young adults with serious mental illness. Future research should confirm these findings, assess longer-term outcomes, and examine implementation facilitators and barriers.

OBJECTIVES: The COVID-19 pandemic stimulated an unprecedented expansion in use of video and telephone visits (televisits) for routine specialty care as a substitute for in-person clinic visits. However, the sustainability of televisit use for specialty care delivery following the pandemic is unclear. STUDY DESIGN/METHODS: In this descriptive, retro-spective study of national Veterans Health Administration (VHA) data, we assessed total outpatient visit volume by month in 9 specialties (cardiology, dermatology, eye care, gastroenterology [GI]/hepatology, neurosurgery, orthopedics, podiatry, substance use disorder [SUD], and urology) at all VHA facilities in the US between January 2019 (pre-COVID-19) and September 2023 (representing late phases of health system recovery post COVID-19). We also categorized outpatient visits by modality (in person, telephone, video) and assessed time trends in the proportion of total outpatient visits in each specialty delivered by televisit. Descriptive statistics were used to summarize the study findings. RESULTS: Although total visit volumes in most VHA specialties had returned to pre-COVID-19 baselines by the end of the study period, they did not fully rebound in others, suggesting persistent care gaps. Televisit use increased from a mean of 7% in quarter 1 (Q1) 2019 to 54% in Q2 2020, then decreased modestly to 27% of all specialty visits by Q3 2023. The specialties with the highest sustained televisit use in Q3 2023 were SUD and GI, despite restored in-person visit availability. The use of telephone visits exceeded the use of video visits throughout the study period. CONCLUSIONS: Our findings suggest that televisits will likely remain an important visit modality for patients in the postpandemic era.

OBJECTIVE: This study aimed to assess the impact of curricular content reduction in a 3-year integrated course sequence in a Doctor of Pharmacy curriculum on student-reported mental and physical health. METHODS: A 3-hour, 5-days-a-week integrated course sequence spanning 3 years of a curriculum was transitioned to a 3-hour, 4-days-a-week course, representing 207 h of reduced in-class time. After implementation, first- through third-year student pharmacists were asked to complete a 23-item voluntary survey regarding the impact of the curricular change on their mental and physical health, how they spent time on the non-Integrated Learning Experience course day, and additional demographic and social characteristics. Respondents were asked to participate in follow-up focus group sessions to elucidate the findings of the survey. RESULTS: A total of 197 students (50.3% response rate) representing the classes of 2024, 2025, and 2026 responded to the survey, and 15 students participated in 1 of 4 focus group sessions. Most students indicated a preference for the 4-days-a-week over the 5-days-a-week course and reported improvement in mental and physical health during the 4-days-a-week course. Most students used the additional time to study or complete assignments, while many third-year students used it to work, but many also used it to complete personal errands and activities, which led to a positive impact on their well-being. CONCLUSION: Student self-reported mental and physical health improved with a reduction in curricular content by 1 course session (3 h) per week.

BACKGROUND: Uncomplicated urinary tract infections (uUTIs) are one of the most common outpatient infections in the United States. Despite this, there are limited data on the impact of oral antibiotic treatment failure (TF) on health care resource utilization (HCRU) and costs for patients with empirically treated uUTIs. OBJECTIVE: To describe all-cause total health care costs in female patients with uUTIs who fail (TF cohort) and who do not fail (no-TF cohort) initial, empirically prescribed, oral antibiotic treatment. Secondary objectives were to describe all-cause HCRU and UTI-related HCRU and costs in the TF cohort and no-TF cohort. METHODS: This study used deidentified electronic health record (EHR) data for female patients aged 12 years and older collected from a US Integrated Delivery Network between January 2016 and January 2023. Eligibility criteria included a uUTI outpatient diagnosis, empirical antibiotic prescription within ±5 days of index uUTI diagnosis, and 12 months or more of EHR activity pre-index and post-index. TF was defined as at least 1 of the following within 28 days after the index date (date of first antibiotic treatment within 5 days of first uUTI diagnosis): second oral antibiotic prescription; intravenous antibiotic administration; or emergency department (ED) or inpatient stay with UTI listed as the primary diagnosis (index uUTI excluded). HCRU and costs 12 months post-index were captured by setting of care, with medical and pharmacy cost estimates based on the most recent available Centers for Medicare and Medicaid Services fee schedule reimbursement rates and prescription costs. Propensity score matching (1:1) was used to control for cohort imbalances. RESULTS: Of 28,460 patients with a uUTI diagnosis, 4,330 (15.2%) experienced empirical antibiotic TF. Mean age of matched TF and no-TF patients (3,957 per cohort) was 53 years; 95% and 96%, respectively, were White. During the index uUTI episode, the TF cohort had higher mean total all-cause costs ($1,369 vs $482; P < 0.001) and UTI-related costs ($392 vs $78; P < 0.001) and a higher proportion of the TF cohort compared with the no-TF cohort had all-cause inpatient stays (3.1% vs 0.5%; P < 0.001) and ED visits (19.1% vs 7.6%; P < 0.001). All-cause and UTI-related total costs remained significantly higher in the TF cohort across time intervals during the 12-month post-index period, including the 181 to 365 days interval. CONCLUSIONS: Empirical antibiotic TF in female patients with uUTIs results in significantly increased HCRU and costs during the uUTI episode and beyond.

Understanding the impact of medications for opioid use disorder on health related quality of life (QOL) may help to explain why few individuals with legal involvement remain in treatment, specifically those receiving opioid antagonists. QOL is an established predictor of treatment retention and has been shown to improve with some treatment for opioid use disorder. Yet limited research has examined QOL with opioid antagonists. We examined the impact of extended release naltrexone (XR-NTX) on QOL and retention in treatment in a randomized, multi-site trial of individuals with legal involvement. Methods: The participants were 308 community-dwelling adults with current or recent legal involvement with opioid dependence at five site across United States. They were randomized to receive XR-NTX or treatment as usual for 6 months. QOL was measured every 2 weeks using Euro QOL individual items, summary index score, and health state today metric. Results: No significant difference in QOL scores were observed between the two groups at the completion of active treatment or on follow up at 52 and 78 weeks. There were no time effects of treatment on scores. Contrary to expectation, baseline and average QOL did not predict retention in treatment. Conclusion: In contrast to prior research, our findings did not demonstrate significant changes (improvements or decreases) in QOL associated with XR-NTX treatment. Clinicians may consider that individuals receiving XR-NTX may not experience changes in perceived well-being in response to treatment and consider discussing with patients that they may not necessarily perceive improvement in their QOL. This may help to ground patient's expectations about the effects of treatment and potentially reduce attrition from treatment with opioid antagonists.

OBJECTIVES: There has been a rapid increase in the presence of illicitly manufactured fentanyl in the heroin drug supply. Buprenorphine is an effective treatment for heroin and prescription opioid use disorder; however, little is known about treatment outcomes among people using fentanyl. We compared 6-month treatment retention and opioid abstinence among people initiating buprenorphine treatment who had toxicology positive for heroin compared to fentanyl at baseline. METHODS: Retrospective cohort study of 251 adult patients initiating office-based buprenorphine treatment who had available toxicology testing across an academic health system between August 2016 and July 2017. Exposure was assessed at baseline before initiating buprenorphine and was categorized as negative toxicology (n = 184) versus fentanyl positive toxicology (n = 48) versus heroin positive toxicology (n = 19). RESULTS: Six-month treatment retention rates were not different between the fentanyl positive and heroin positive groups [38% (n = 18) vs 47% (n = 9); P = 0.58], or between the fentanyl positive and the negative toxicology group [38% (n = 18) vs 51% (n = 93); P = 0.14]. Opioid abstinence at 6 months among those who had testing did not differ between the fentanyl positive and the heroin positive group [55% (n = 6) vs 60% (n = 6); P = 0.99]. The fentanyl positive group had a lower abstinence rate at 6 months compared to those with negative toxicology at baseline [55% (n = 6) vs 93% (n = 63); P = 0.004]. Mean initial buprenophine dosage did not differ between groups. CONCLUSIONS: Buprenorphine treatment retention and abstinence among those retained in treatment is not worse between people using fentanyl compared to heroin at treatment initiation. Both groups have lower abstinence rates at 6 months compared to individuals with negative toxicology at baseline. These findings suggest that people exposed to fentanyl still benefit from buprenorphine treatment.