Background: Following the national implementation of the Affordable Care Act (ACA) in 2014, barriers still exist that limit the adoption of substance use treatment (SUT) services in mainstream health care (MHC) settings in the United States. This study provides an overview of current evidence on barriers and facilitators to integrating various SUT services into MHC. Methods: A systematic search was conducted with the following databases: "PubMed including MEDLINE ", "CINAHL ", "Web of Science ", "ABI/Inform ", and "PsycINFO. " We identified barriers and/or facilitators affecting patients, providers, and programs/systems. Results: Of the 540 identified citations, 36 were included. Main barriers were identified for patients (sociodemographics, finances, confidentiality, legal impact, and disinterest), providers (limited training, lack of time, patient satisfaction concerns, legal implications, lack of access to resources or evidence-based information, and lack of legal/regulatory clarity), and programs/systems (lack of leadership support, lack of staff, limited financial resources, lack of referral networks, lack of space, and lack of state-level support). Also, we recognized key facilitators pertaining to patients (trust for providers, education, and shared decision making), providers (expert supervision, use of support team, training with programs like Extension for Community Health Outcomes (ECHO), and receptivity), and programs/systems (leadership support, collaboration with external agencies, and policies e.g., those expanding the addiction workforce, improving insurance access and treatment access). Conclusions: This study identified several factors influencing the integration of SUT services in MHC. Strategies for improving SUT integration in MHC should address barriers and leverage facilitators related to patients, providers, and programs/systems.

Purpose: Despite strategies prohibiting e-cigarettes use and purchase, the literature suggests continued use and access by adolescents. Guided by the Socio-Ecological Model, we examined sources and types of e-cigarettes along with the associated frequency of use among U.S school-going adolescents. Methods: We used the 2019 National Youth Tobacco Survey comprising U.S middle and high schoolers (n=19,018). Multinomial logistic regression was conducted to evaluate associations between sources and types of e-cigarettes, and the frequency of use while controlling for covariates. Results: The final sample was 3,537 with 76.9% high schoolers, 51.6% males, and 59.7% prefilled pods/cartridges users (JUUL). Past-month e-cigarette use was 60.8% for 1-10 days, 14.3% for 11-20 days, and 24.9% for 21-30 days. Sources adolescents obtained e-cigarettes included retail stores (20.1%), vape shops (15.2%), internet (7.1%), social networks (74.0%), and unknown sources (5.9%). Compared to 1-10 days, 21-30 days e-cigarette use was higher among participants who obtained e-cigarettes from retail stores [OR= 3.03; 95% CI= 3.009-3.046; P<0.001], vape shops [OR= 3.42; 95% CI= 3.393-3.439; P<0.001], and the internet [OR= 1.85; 95% CI= 1.839-1.872; P<0.001] than from other sources, but lower when obtained from social networks [OR= 0.63; 95% CI= 0.628-0.636; P<0.001]. Using e-cigarettes like JUUL was associated with higher odds of 21-30 days [OR= 1.11; 95% CI= 1.106-1.120; P<0.001] use than refillable e-cigarette tank. Conclusion: Factors within the organizational and community levels, including types (JUUL) and sources of e-cigarette (retail stores, vape shops, and internet), were associated with a higher frequency of past-month use.

Objective: Identify factors associated with readmissions following myocardial infarction. Background: The Hospital Readmission Reduction Program, implemented in 2012 under the Affordable Care Act, penalizes hospitals with higher rates of readmission, defined as admission within 30 days from prior hospital discharge, than the national average for targeted diagnoses. One of the more common causes of readmission is myocardial infarction (MI). Southern Appalachian hospitals have readmission rates for MI that exceed the national average, resulting in financial penalties for these hospitals. Methods: Retrospective chart review study evaluating readmissions within 30 days of hospital discharge following MI in medical facilities in Southern Appalachia from 2014 to 2017. Results: There were 3,913 patients admitted to hospitals in Southern Appalachia between 2014 to 2017 with an MI; of these, 439 patients were readmitted within 30 days from previous hospital discharge. Patients with length of stay (LOS) less than 2 days were 50.3% (OR 0.497

Objective: Recognize opportunities to mitigate readmissions following hospitalization for heart failure. Background: Heart failure (HF) is the leading cause of hospital readmissions, defined as hospital admissions that occur within 30 days of previous hospital discharge. The Hospital Readmission Reduction Program within the Affordable Care Act penalizes hospitals for readmission rates that surpass the national average for targeted diagnoses including HF. Southern Appalachia has higher HF readmission rates when compared to the national average, even among similar patients with matched comorbidities. These hospitals subsequently incur heavy financial penalties. Methods: Institutional review board (IRB) approved retrospective chart review study analyzing medical facilities in Southern Appalachia to determine factors contributing to higher readmission rates secondary to HF from 2014 to 2017. Results: Data from 3,555 patients’ charts were reviewed who had an index admission diagnosis of HF and were discharged between 2014 to 2017; 818 of these patients were readmitted within 30 days. Length of stay (LOS) of more than 5 days was significantly associated with an increased readmission rate (p = 0.0347), and current tobacco use was also significantly associated with an increased readmission rate (p = 0.0214). Use of angiotensin converting enzyme inhibitors (ACE-I) upon discharge was associated with a decrease in likelihood of readmission (p = 0.0014). Other medications prescribed at discharge (beta blockers, aldosterone antagonists, diuretics, antiplatelet, and statin) were not associated with affecting the readmission rate. Comorbidities including diabetes mellitus (DM), chronic renal failure (CRF), and psychiatric diagnoses were all associated with significantly increasing the readmission rate (p = 0.0468, p = 0.0061, and p = 0.0085, respectively). The discharge time of the day, day of the week, and month of the year were not associated with affecting the readmission rate. The type of payor for the medical care, the discharge location, and whether patients received a palliative medicine consult while hospitalized also did not affect the readmission rate. Conclusion: Strategies to mitigate readmission rates secondary to HF include limiting LOS to less than 5 days, providing smoking cessation education, and prescribing an ACE-I at the time of discharge. Methods to minimize development of DM and CRF through controlling contributing risk factors and ensuring appropriate management of psychiatric disorders are additional platforms for decreasing readmission rates for HF. Counter to previous assumptions, the discharge time of the day, day of the week, and month of the year did not affect the rate of readmissions, nor did the type of payor, the discharge location, or whether patients received palliative medicine consults.

BACKGROUND:Rates of accidental overdose mortality from substance use disorder (SUD) have risen dramatically in the United States since 1990. Between 1999 and 2004 alone rates increased 62% nationwide, with rural overdose mortality increasing at a rate 3 times that seen in urban populations. Cultural differences between rural and urban populations (e.g., educational attainment, unemployment rates, social characteristics, etc.) affect the nature of SUD, leading to disparate risk of overdose across these communities.METHODS:Multiple-groups latent class analysis with covariates was applied to data from the 2011 and 2012 National Survey on Drug Use and Health (n=12.140) to examine potential differences in latent classifications of SUD between rural and urban adult (aged 18years and older) populations. Nine drug categories were used to identify latent classes of SUD defined by probability of diagnosis within these categories. Once the class structures were established for rural and urban samples, posterior membership probabilities were entered into a multinomial regression analysis of socio-demographic predictors' association with the likelihood of SUD latent class membership.RESULTS:Latent class structures differed across the sub-groups, with the rural sample fitting a 3-class structure (Bootstrap Likelihood Ratio Test P value=0.03) and the urban fitting a 6-class model (Bootstrap Likelihood Ratio Test P value<0.0001). Overall the rural class structure exhibited less diversity in class structure and lower prevalence of SUD in multiple drug categories (e.g. cocaine, hallucinogens, and stimulants).CONCLUSIONS:This result supports the hypothesis that different underlying elements exist in the two populations that affect SUD patterns, and thus can inform the development of surveillance instruments, clinical services, and prevention programming tailored to specific communities.

In 2008, The American College of Cardiology/American Heart Association/Heart Rhythm Society issued revised guidelines for automatic implantable cardioverter-defibrillators (AICD). We hypothesized that these guidelines have influenced AICD implantation rates. We queried the NIS database to identify

The IDSA Community-Acquired Pneumonia (CAP) Guideline recommends ceftriaxone in combination with doxycycline as an alternative to combination therapy with ceftriaxone and azithromycin for non-intensive care unit (ICU) patients hospitalized with CAP. This is an attractive alternative regimen due to recent concerns of increased cardiovascular risk associated with azithromycin. The objective of this study was to compare the clinical outcomes of azithromycin and doxycycline each in combination with ceftriaxone for non-ICU Veterans hospitalized with CAP. This retrospective cohort study included Veterans with pneumonia admitted to the VA MidSouth Healthcare Network from January 2007 to January 2015 who received ceftriaxone plus either azithromycin or doxycycline within 48 hours of admission. Demographics, modified CURB-65, Charleston Comorbidity Index (CCI), antimicrobials received, and microbiology data were obtained. A composite outcome was used to assess clinical failure and included either broadened antimicrobial coverage during index hospitalization, mortality, readmission, or emergency department visit within 30 days. Univariate and multivariate logistic regression were performed to identify risk factors associated with clinical outcomes. 3788 patients met inclusion criteria: 3711 in the azithromycin group and 77 in the doxycycline group. These were well-matched according to CAP severity and comorbidities. There was no statistical difference in the composite outcome between the azithromycin and doxycycline groups (44.3% vs 51.9%, P = 0.18). Multivariate analysis identified positive blood culture (OR 5.81, 95% CI 2.69–12.55), CURB-65 [2 vs 0] (OR 1.24, 95% CI 1.05–1.47), CURB-65 [≥3 vs 0] (OR 2.4, 95% CI 1.22–4.71) and CCI (OR 1.1, 95% CI 1.06–1.14) as risk factors for the composite outcome. Receipt of doxycycline was not associated with components of the composite outcome in secondary analyses. Doxycycline was not associated with a statistical difference in the composite outcome for non-ICU Veterans hospitalized for CAP compared with azithromycin. These data offer support for the inclusion of doxycycline as an alternative regimen in current IDSA recommendations. All authors: No reported disclosures.

To determine the level of public health competency and training in the existing Tennessee Department of Health (TDH) workforce, an anonymous survey was implemented electronically. Questions were based on the Council on Linkages Core Public Health Competencies, a consensus set of skills identified by the Council on Linkages Between Academia and Public Health Practice as being desirable for the delivery of the Essential Public Health Services. All 5,178 active TDH employees were eligible to participate in the survey. In each of the core competency areas Leadership Level respondents scored consistently higher than Management Level or Entry Level, and Management Level respondents scored higher than Entry Level respondents. However, overall findings indicate that the eight core competency areas are not fully integrated into the TDH, and that there are clear training needs with high priority. Needs scores were calculated by dichotomizing responses into ‘Unaware/Aware’ and ‘Knowledgeable/Proficient’, with the ‘Unaware/Aware’ category indicating a training need in that area. When considering responses from all three Tiers, needs scores greater than 50% were found for six of the eight core competency areas. These results identify opportunities for improvements through a coordinated training strategy. Findings also highlight the need for deliberate planning activities related to diversity and hiring, as a significant percentage of employees are predicted to retire in the near future. Given resource constraints within TDH, training activities should be directed to increase competencies that are likely to have the greatest impact on the mission of the Department of Health.

The rates of non-medical prescription drug use in the United States (U.S.) have increased dramatically in the last two decades, leading to a more than 300% increase in deaths from overdose, surpassing motor vehicle accidents as the leading cause of injury deaths. In rural areas, deaths from unintentional overdose have increased by more than 250% since 1999 while urban deaths have increased at a fraction of this rate. The objective of this research was to test the hypothesis that cultural, economic, and environmental factors prevalent in rural America affect the rate of substance use disorder (SUD) in that population, and that diagnosis of these disorders across rural and urban populations may not be generalizable due to these same effects. This study applies measurement invariance analysis and factor analysis techniques: item response theory (IRT), multiple indicators, multiple causes (MIMIC), and latent class analysis (LCA), to the DSM-IV abuse and dependency diagnosis instrument. The sample used for the study was a population of adult past-year illicit drug users living in a rural or urban area drawn from the 2011-2012 National Survey on Drug Use and Health data files (N = 3,369| analyses 1 and 2; N = 12,140| analysis 3). Results of the IRT and MIMIC analyses indicated no significant variance in DSM item function across rural and urban subgroups ; however, several socio-demographic variables including age, race, income, and gender were associated with bias in the instrument. Latent class structures differed across the sub-3 groups in quality and number, with the rural sample fitting a 3-class structure and the urban fitting 6-class model. Overall the rural class structure exhibited less diversity and lower prevalence of SUD in multiple drug categories (e.g. cocaine, hallucinogens, and stimulants). This result suggests underlying elements affecting SUD patterns in the two populations. These findings inform the development of surveillance instruments, clinical services, and public health programming tailored to specific communities. and Charlie, the six lights that guide my way. 6 ACKOWLEDGEMENTS I would like to thank my committee (Drs Alamian, Pack, McBee, and Zheng) for all your efforts on my behalf. Through the process of developing this research I have been overwhelmed by your generosity and wisdom. I will always be grateful for the time you've each spent with me over the last three years. In addition I would like to thank Dr. Megan Quinn for her input in the early stages of the proposal development, …

Type: Work in Progress. Background: Treatment resistance is common in patients with depression and schizophrenia, with many patients failing greater than two adequate medication trials. Pharmacogenomic testing provides a means to optimize medication therapy by identifying anomalies in drug metabolism, which could lead to lack of efficacy or increased risk for toxicity. Identifying metabolic anomalies provides the ability to identify which medication therapies are most likely to be safe and effective for a particular patient. This study will establish a new pharmacogenomic testing service and evaluate the clinical utility of pharmacogenomic testing in patients with treatment resistant depression and schizophrenia. Objectives: 1. Establish a new clinical consult service providing pharmacogenomic testing for patients with treatment resistant depression and schizophrenia. 2. Determine which, if any, pharmacogenomic anomalies are present in treatment refractory depression or schizophrenia. 3. Determine if any medication changes were made based on the results of the pharmacogenomic panel. Methods: A new service providing pharmacogenomic testing was established at the Chillicothe VAMC. We contracted with a pharmacogenomic testing company to provide testing services. A pilot project for genomic testing of patients with treatment resistance was developed and approved by the Chief of Staff. Patients with treatment refractory depression or schizophrenia (failing 2 or more adequate medication trials) were eligible for testing. The pharmacogenomic testing panel included CYP2D6, CYP2C9, CYP2C19, CYP1A2, CYP3A4, CYP3A5, MTHFR, SULT4A1 and SLC6A4. At this point, approximately 15 patients have been tested through the pilot project. The protocol to compile the results of the genomic testing has been approved by IRB and is awaiting R&D approval. Demographic information (gender, age, race, psychiatric diagnosis) will be collected. Presence of specific pharmacogenomic anomalies and whether medication changes were made based on testing will also be recorded. Demographics and outcomes will be analyzed using descriptive statistics. Data collection and analysis will be completed in February. Outcomes: We will report the process of developing a service within the VA, along with which, if any, pharmacogenomic anomalies are present in treatment refractory depression or schizophrenia, and if medication changes are made based on test results. Safety of Benzodiazepine Use Among Four Patient Groups with Post-Traumatic Stress Disorder (PTSD) in a VA Medical Center Katie T. Blissit, PharmD, BCPS, Jennifer N. Houser, PharmD, BCPP, CGP, Kevin G. Brittain, PharmD, BCPS All parties are affiliated with the William Jennings Bryan Dorn Veterans Affairs Medical Center Abstract Type: Original Research. Purpose: VA/DoD Clinical PracticeType: Original Research. Purpose: VA/DoD Clinical Practice Guidelines recommend against long-term use of benzodiazepines (BZD) for PTSD due to lack of benefit and potential harm. The purpose of this study was to compare safety outcomes in four subject groups with PTSD (1: PTSD alone, 2: PTSD and Alcohol Use Disorder, 3: PTSD and Traumatic Brain Injury (TBI), 4: PTSD, Alcohol Use Disorder, and TBI) receiving BZD to those not receiving BZD. Methods: Adult veterans with ICD-9 coded visits for PTSD during October 1999-2014 were screened, and 9744 subjects (1290 received BZD) were included in this retrospective cohort study. Subjects with comorbid substance-induced mood disorder, MDD, Bipolar disorder, Schizophrenia, Schizoaffective disorder were excluded. Subjects were assigned to the BZD group if they received BZD therapy at least twice with the second fill being no later than 30 days past the eligible refill date. Primary outcome was all-cause mortality. Secondary outcomes included rates of hospitalizations and emergency room (ER) visits. Duration of BZD use, rates of comorbid anxiety disorder and/or substance abuse were evaluated. BZD possession ratio (BPR) and Charlson Comorbidity Index (CCI) scores were calculated and included in this analysis. The BPR estimated adherence using the total duration of therapy and days’ supply. Results: Demographic (race, age, sex, mean CCI, comorbid anxiety) characteristics were statistically different overall. Comorbid substance abuse was more prevalent in subjects with PTSD alone that received BZD vs. those that did not (4.9% vs. 3.5%, p 1⁄4 0.017). Subjects that received BZD were more likely to be Caucasian and have comorbid anxiety. Mean BPR ranged from 0.69-0.80 among groups. Mean CCI scores were higher in BZD subjects overall (1.66 vs. 0.90, p < 0.001); however, BZD use was associated with higher rates of all-cause mortality within groups 1 and 2 for subjects with CCI score of 0 or 1 (N 1⁄4 8409; compared independently, all OR’s >2.2, all p-value’s <0.03). BZD use was associated with higher rates of hospitalizations and ER visits per 100 patient years for groups 1-3 (all p-value’s <0.001). Conclusions: Benzodiazepine use was associated with higher rates of all-cause mortality, hospitalizations and ER visits. Therapeutic Effects of Intranasal Insulin Aspart on Cognitive Function in Post-operative Delirium Lindsey Peters, PharmD, Robert Melashenko, MD, Michael Webster, MD, Matthew Kauflin, PharmD, BCPS, Candice Hithe, DO, Nicholas Wolters, PharmD, Bryan Lizza, PharmD, BCPS Journal of Pharmacy Practice 2015, Vol. 28(3) 315-375 a The Author(s) 2015 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0897190015582204 jpp.sagepub.com 1. Grandview Medical Center, Department of Pharmacy, Dayton, OH 45405; 2. Ohio Northern University, Ada, OH 45810; 3. Grandview Medical Center, Department of Anesthesiology, Dayton, OH 45405; 4. Northwestern Memorial Hospital, Department of Pharmacy, Chicago, IL 60611 Abstract Type: Work in Progress. Background: Delirium, defined as a change in cognition characterized by an acute onset of inattention and either disorganized thinking or a change in the level of consciousness, is a complication encountered in post-operative patients. Delirium has a large economic burden as well as poor patient outcomes. Current treatment options are limited; therefore, there is considerable interest in new pharmacologic options. There is convincing evidence that intranasal insulin improves cognition in humans. Objectives: Evaluate the use of intranasal insulin aspart on cognitive function in patients with post-operative delirium. The primary outcome measure is the duration of Confusion Assessment Method-Intensive Care Unit (CAM-ICU) positive delirium. There are various secondary outcome measures. Methods: All patients undergoing surgery at Grandview Medical Center will be asked to participate in this randomized, double-blind, placebocontrolled trial, with a target enrollment of 80 patients. Patients will be identified for recruitment during outpatient pre-admission testing and inpatient anesthesia pre-operative screening. After providing informed consent, baseline cognitive function will be assessed using the Telephone Interview for Cognitive Status (TICS). If all inclusion criteria are met and post-operative CAM-ICU delirium occurs, the patient will be randomized to receive either intranasal insulin aspart 40 units or normal saline 0.4 mL, both given as a single dose. The CAM-ICU will be performed again fifteen minutes following treatment and then daily until patient discharge. Follow-up TICS assessment will occur 30 days post-discharge. Patient demographics, past medical history, and admission data (cognition test results, surgical information, blood glucose, laboratory results, and nasal irritation score) will be collected. This study received network IRB approval. Results: After screening hundreds of patients, 54 patients provided informed consent. Of those 54 patients, only 5 developed post-operative delirium. Preliminary data shows a trend towards decreased duration of delirium with treatment group ‘‘A’’ (n 1⁄4 2) versus treatment group ‘‘B’’ (n 1⁄4 3). The study team is evaluating ways to increase recruitment and capture more participants. We expect to complete patient recruitment by April 2015. All data will be reviewed by a statistician. Differences in duration of CAM-ICU delirium will be calculated using a Chi-Square test. Descriptive statistics will be used to examine demographic data.Type: Work in Progress. Background: Delirium, defined as a change in cognition characterized by an acute onset of inattention and either disorganized thinking or a change in the level of consciousness, is a complication encountered in post-operative patients. Delirium has a large economic burden as well as poor patient outcomes. Current treatment options are limited; therefore, there is considerable interest in new pharmacologic options. There is convincing evidence that intranasal insulin improves cognition in humans. Objectives: Evaluate the use of intranasal insulin aspart on cognitive function in patients with post-operative delirium. The primary outcome measure is the duration of Confusion Assessment Method-Intensive Care Unit (CAM-ICU) positive delirium. There are various secondary outcome measures. Methods: All patients undergoing surgery at Grandview Medical Center will be asked to participate in this randomized, double-blind, placebocontrolled trial, with a target enrollment of 80 patients. Patients will be identified for recruitment during outpatient pre-admission testing and inpatient anesthesia pre-operative screening. After providing informed consent, baseline cognitive function will be assessed using the Telephone Interview for Cognitive Status (TICS). If all inclusion criteria are met and post-operative CAM-ICU delirium occurs, the patient will be randomized to receive either intranasal insulin aspart 40 units or normal saline 0.4 mL, both given as a single dose. The CAM-ICU will be performed again fifteen minutes following treatment and then daily u

Farmers' markets are increasingly promoted for their potential to improve access to healthful foods. University campuses are strategic settings for farmers' markets, because they could improve access to fresh, local produce for large and diverse communities-including college students, who are at risk for poor dietary intake. Universities also offer resources that facilitate farmers' markets, such as built-in communication channels, common areas, and student volunteers. However, literature describing how to establish campus-based farmers' markets is limited. We describe the process of developing and operating a student-driven, campus-based farmers' market at a public university in the Appalachian region of the United States.

In an effort to bridge the gap between public health practice and academia, the Health Resources and Services Administration-funded Tennessee Public Health Training Center (LIFEPATH) has supported establishment of an academic health department (AHD) involving the East Tennessee State University College of Public Health (COPH) and the Sullivan County Regional Health Department (SCRHD). The SCRHD identified a need to increase internal capacity to conduct ongoing community health assessment and community-centered practice. Similarly, the COPH recognized the need to expand evidence-based practice implementation and evaluation opportunities for public health students. Personnel from the SCRHD, LIFEPATH, and the COPH developed a formal AHD agreement during the summer of 2012 and launched the program the subsequent fall semester. One aspect of the COPH/SCRHD/LIFEPATH model that addresses financial barriers experienced by other AHDs is the competitive awarding of the coordinator position to a doctor of public health student from the COPH, demonstrating investment in the model by the college. The doctor of public health student gains leadership experience through project management, coordination of the local health council, and day-to-day facilitation of undergraduate and master's student interns. The SCRHD benefits from the formal academic background of graduate-level interns dedicated to working in the community. This AHD framework offers an opportunity for doctoral-level students to develop practical leadership skills in a health department while enhancing the capacity of the SCRHD and the COPH to serve their community and stakeholders.