Literature Collection

BACKGROUND: Diabetes self-management education and support (DSMES) is an evidence-based intervention that improves outcomes for people with diabetes, but uptake is <10%. We conducted a pilot pragmatic trial to increase DSMES in rural primary care clinics that integrated health information technology with a quality improvement (QI) learning collaborative. METHODS: Two healthcare systems from rural Kentucky participated in the study. Within each system, 2 clinics received the intervention and 1 clinic served as a control (N = 6 clinics). Each intervention clinic identified a QI team (5-6 individuals) who participated in a 9-month QI learning collaborative followed by 5 months of follow-up. Our primary outcome was DSMES referrals; secondary outcomes were DSMES attendance and percentage with A1c >9%. RESULTS: The 6 study clinics served 1,803 patients with diabetes; n = 1083 (60.1%) from 4 intervention clinics and n = 720 (39.9%) from 2 control clinics. DSMES referrals significantly increased in the intervention clinics compared to the control clinics (31.7% vs 0.1%, P < .001) and continued to increase throughout 5-month follow-up (40.0% vs 0.1%, P < .001). CONCLUSIONS: A structured QI intervention can significantly increase DSMES referral rates in primary care clinics. Findings highlight the potential of systems-level approaches to address persistent gaps in diabetes care delivery in rural settings. CLINICAL TRIAL REGISTRY: Using Practice Facilitation and Operationalizing Referral Information Technology to Increase DSMES Utilization (Clinicaltrials.gov registration number no. NCT05472142). CLINICALTRIALS: gov URL (https://clinicaltrials.gov/study/NCT05472142).

OBJECTIVE: To develop effective pharmacy-based interventions to mitigate harm from opioid use disorders. Programs include responsible opioid prescribing, expanded access to medication-assisted treatment (MAT), naloxone, and community interventions. SETTING: Clinical pharmacists practicing at Indian Health Service (IHS) locations in the Southwest, Midwest, and Great Lakes regions. These pharmacists serve culturally diverse American Indian populations throughout the United States and interface with tribal and federal programs to impact the opioid epidemic in Indian Country. PRACTICE DESCRIPTION: Pharmacists have reduced barriers to care by expanding clinical practices to include novel approaches in pain management clinics and MAT programs. PRACTICE INNOVATION: As part of a multidisciplinary team, IHS pharmacists provide comprehensive patient care while focusing on the prevention of opioid dependence and opioid overdose death. EVALUATION: Pharmacists have also expanded professional competencies to include coprescribing naloxone and training first responders on naloxone use. RESULTS: Pharmacists within IHS have proactively completed advanced training on responsible opioid prescribing, augmented services to increase access to MAT for American Indians and Alaska Natives, and increased access to naloxone for opioid overdose reversal. Pharmacists have also developed a comprehensive training program and program measurement tools for law enforcement officers serving in tribal communities. These materials were used to train 350 officers in 6 districts and conduct a mass naloxone dispensing initiative across Indian Country. Pharmacists have consequently developed successful community coalitions that are focused on saving lives. CONCLUSIONS: Pharmacist involvement in key initiatives including responsible opioid prescribing, expanded access to MAT, and expanded access to naloxone for trained first responders, coupled with an emphasis on enhanced education, illustrates pharmacists' impact with the opioid epidemic.

BACKGROUND: Naloxone co-prescribing to individuals at increased opioid overdose risk is a key component of opioid overdose prevention efforts. OBJECTIVE: Examine naloxone co-prescribing in the general population and assess how co-prescribing varies by individual and community characteristics. DESIGN: Retrospective cross-sectional study. We conducted a multivariable logistic regression of 2017-2018 de-identified pharmacy claims representing 90% of all prescriptions filled at retail pharmacies in 50 states and the District of Columbia. PATIENTS: Individuals with opioid analgesic treatment episodes > 90 days MAIN MEASURES: Outcome was co-prescribed naloxone. Predictor variables included insurance type, primary prescriber specialty, receipt of concomitant benzodiazepines, high-dose opioid episode, county urbanicity, fatal overdose rates, poverty rates, and primary care health professional shortage areas. KEY RESULTS: Naloxone co-prescribing occurred in 2.3% of long-term opioid therapy episodes. Medicaid (aOR 1.87, 95%CI 1.84 to 1.90) and Medicare (aOR 1.48, 95%CI 1.46 to 1.51) episodes had higher odds of naloxone co-prescribing than commercial insurance episodes, while cash pay (aOR 0.77, 95%CI 0.74 to 0.80) and other insurance episodes (aOR 0.81, 95%CI 0.79 to 0.83) had lower odds. Odds of naloxone co-prescribing were higher among high-dose opioid episodes (aOR 3.19, 95%CI 3.15 to 3.23), when concomitant benzodiazepines were prescribed (aOR 1.12, 95%CI 1.10 to 1.14), and in counties with higher fatal overdose rates. CONCLUSION: Co-prescription of naloxone represents a tangible clinical action that can be taken to help prevent opioid overdose deaths. However, despite recommendations to co-prescribe naloxone to patients at increased risk for opioid overdose, we found that co-prescribing rates remain low overall. States, insurers, and health systems should consider implementing strategies to facilitate increased co-prescribing of naloxone to at-risk individuals.

BACKGROUND: Since 2010 there has been a growing population of refugees and asylum seekers in Latin America. This study sought to investigate the perceived experiences and healthcare needs of refugees and asylum seekers of Latin American origin in Chile in order to identify main barriers to healthcare and provide guidance on allied challenges for the public healthcare system. METHODS: Descriptive qualitative case study with semi-structured interviews applied to refugees and asylum seekers (n = 8), healthcare workers (n = 4), and members of Non-Governmental Organizations and religious foundations focused on working with refugees and asylum seekers in Chile (n = 2). RESULTS: Although Chilean law guarantees access to all levels of healthcare for the international migrant population, the specific healthcare needs of refugees and asylum seekers were not adequately covered. Primary care and mental healthcare were the most required types of service for participants, yet they appeared to be the most difficult to access. Difficulties in social integration -including access to healthcare, housing, and education- upon arrival and lengthy waiting times for legal status of refugees also presented great barriers to effective healthcare provision and wellbeing. Healthcare workers and members of organizations indicated the need for more information about refugee and asylum-seeking populations, their rights and conditions, as well as more effective and tailored healthcare interventions for them, especially for emergency mental healthcare situations. CONCLUSIONS: All participants perceived that there was disinformation among institutional actors regarding the healthcare needs of refugees and asylum seekers in Chile. They also perceived that there were barriers to access to primary care and mental healthcare, which might lead to overuse of emergency services. This study highlights a sense of urgency to protect the social and healthcare needs of refugees and asylum seekers in Latin America.